Ontario Healthcare

The majority of job gains in 2022 were concentrated in full-time, private sector, and permanent positions.

The average hourly wage rate in Ontario increased 4.2 per cent to $32.94 in 2022, marking the second consecutive year when wage growth did not keep up with inflation. Only two out of 16 industry groups and five out of 34 occupation groups saw their wages grow above the 6.8 per cent average annual CPI inflation rate in 2022.

Hiring challenges persisted in 2022. Of all job vacancies in Ontario, 36.3 per cent remained unfilled for 90 days or more, reaching a record high in the third quarter of 2022. In addition, a record 5.2 per cent of employees were absent from work either a full week or part of a week due to illness or disability in 2022.

The average annual unemployment rate in the province dropped to 5.6 per cent in 2022, down from 8.1 per cent in 2021.

Annual Employment Change in 2022 (Per Cent)

Public

The average hourly wage of Ontarians increased 4.2 per cent to $32.94 in 2022, below the 6.8 per cent CPI inflation rate. This marked the second consecutive year when wage growth did not keep up with inflation.

Average wage growth for male workers (5.0 per cent) outpaced that for female workers (3.3 per cent).

Wage growth across most industries and occupations did not keep up with inflation Of the 16 major industry groups, only two industries saw their average hourly wage rate increase faster than inflation. Professional, scientific and technical services — an industry which had the second highest average hourly wage rate among all industries as well as the largest increase in employment in 2022 — recorded the strongest annual wage growth (9.0 per cent). The second highest wage growth (8.9 per cent) was recorded by accommodation and food services — an industry which had the lowest average hourly wage rate among all the industries, but the highest rate of job vacancy[2

Across 34 different occupation groups, the average hourly wage for only five occupations increased more than inflation in 2022.[3] Occupation groups that had above-inflation wage growth include legislative and senior management (13.5 per cent), professional occupations in natural and applied sciences (8.0 per cent), labourers in processing, manufacturing and utilities (8.0 per cent), helpers and labourers and other transport drivers, operators and labourers in trades, transport and equipment operators and related occupations (7.5 per cent), and supervisors, central control and process operators in processing, manufacturing and utilities and aircraft assemblers and inspectors (7.2 per cent).

Long-term job vacancies, defined as positions that remained unfilled for 90 days or more, represented 36.3 per cent of all job vacancies in the third quarter of 2022, the highest share on record.

Trades, transport and equipment operators and related occupations and health occupations had the highest proportion of vacancies unfilled for 90 days or more. Close to half the job vacancies in trades, transport and equipment operators and related occupations remained unfilled for 90 days or longer as of the third quarter of 2022.

With most pandemic-related restrictions more fully lifted, the share of Ontario employees who were absent either a full week or part of a week due to illness or disability reached 5.2 per cent in 2022, the highest on record.

Alternatively, the Province could make program cuts or changes to its expansion commitments to achieve its health sector spending plan targets.

the FAO projects a shortfall of 33,000 nurses and PSWs. These nurse and PSW shortages will jeopardize Ontario’s ability to sustain current programs and meet program expansion commitments.

challenges are expected to persist across Ontario’s health care system.

First, given that there is a $21.3 billion health sector funding shortfall, the Province has not allocated sufficient funding to ensure that the 4,500 additional hospital beds can be operated.

In total, the FAO projects that the Province’s health sector spending plan has a net funding shortfall over the six-year period from 2022-23 to 2027-28 of $21.3 billion.

The FAO’s spending forecast assumes wage growth is consistent with existing collective agreements and, for new collective agreements, historical long-term average growth in wages. However, given recent elevated inflation, there is the potential for above-average wage settlements, which would lead to higher than projected spending.

On November 29, 2022, the Ontario Superior Court of Justice ruled that Bill 124, which limits base salary increases for most provincial employees to one per cent per year for a period of three years, was in violation of the Canadian Charter of Rights and Freedoms and was declared to be void and of no effect. The government has appealed this decision. If the government is unsuccessful in its appeal, then provincial spending on wages would be higher than projected in the FAO’s forecast.

If successful, the Province’s measures would add 4,500 new hospital beds from 2019-20 to 2027-28 and free up 2,500 existing beds occupied by ALC patients, for a total increase in available capacity of 7,000 hospital beds. However, the FAO expects that it is unlikely that the Province will achieve the 7,000 hospital beds target under current policies.

Based on current program design and announced commitments, the FAO projects that health sector spending will grow at an average annual rate of 3.6 per cent between 2021-22 and 2027-28, reaching $93.8 billion in 2027-28. In contrast, the funding allocated by the Province in the 2022 Ontario Budget and the 2022 Fall Economic Statement (FES) grows at an average annual rate of 2.5 per cent, reaching $87.8 billion by 2027-28.

New funding could be added to the health sector from a combination of the contingency fund,[5] new federal health transfers or new incremental program spending. On February 7, 2023, the federal government announced changes to health funding arrangements which, as of the writing of this report, the FAO estimates will result in new incremental federal health transfers to the Province totalling $10.9 billion from 2023-24 to 2027-28. If the Province uses all of the $10.9 billion in incremental federal health transfers to increase funding for the health sector spending plan, then the FAO estimates that this new funding would cover approximately half of the health sector funding shortfall identified by the FAO.

Finally, even if the Province achieves its plan to increase available hospital capacity by 7,000 beds by 2027-28, the FAO projects that Ontario will still be 500 beds short of the estimated 7,500 beds needed just to serve the growth in demand for hospital services from Ontario’s growing and aging population. This suggests that without additional measures, Ontario will have less available hospital capacity relative to need in 2027-28 than in 2019-20.

Despite these significant investments, the FAO estimates that there will still be a slight decline in home care and long-term care capacity relative to need compared to 2019-20. This is due to high growth in the number of Ontario seniors over the forecast period, which will significantly increase demand for home care and long-term care services. For home care, the number of nursing and personal care hours per Ontarian aged 65 and over will be about the same in 2024-25 as it was in 2019-20. For long-term care, the number of beds per 1,000 Ontarians aged 75 and over will decline slightly from 71 in 2019-20 to 70 in 2027-28.

Despite the Province’s $858 million investment over three years from 2020-21 to 2022-23, the number of surgeries performed has not returned to pre-pandemic levels. Looking only at months not affected by elective surgery pauses, the average number of surgeries performed in each month from 2020 to 2022 was significantly lower than in 2019. Average monthly surgeries performed were 14 per cent lower in 2020, 12 per cent lower in 2021 and eight per cent lower in 2022 (as of September 2022).

To achieve its surgery waitlist target, the rate of decline in the waitlist would need to be significantly faster than what the Province has achieved up to September 2022.

the Province has yet to record any sustained reduction in the number of these patients waiting for surgery.

As of September 2022, the surgery waitlist had 107,000 long-waiters, which was the highest number recorded since the start of the pandemic. Consequently, without additional measures, the Province will not achieve its goal of reducing the number of patients on the surgery waitlist classified as long-waiters to the pre-pandemic level of 38,000.

As patient volumes in emergency departments have returned to near pre-pandemic levels, emergency department wait times have increased significantly. In 2022-23, the average length of stay in an emergency department for patients admitted to hospitals was 20.9 hours. This is 34 per cent higher than wait times over the five-year period prior to the COVID-19 pandemic and the longest average wait time recorded in over 15 years.

Additionally, as of the writing of this report, there have been at least 145 unplanned emergency department closures in Ontario in 2022. Prior to the emergency department closures in 2022, the FAO is aware of only one unplanned emergency department closure since 2006 due to a lack of doctors.

Emergency department closures are primarily an issue in smaller population centres, while the longest emergency department wait times are more commonly found in hospitals in urban areas. Ontario hospitals have identified a lack of available staff, including nurses and physicians, as the key issue causing longer emergency department wait times and closures.

Overall, while the Province’s measures do address physician shortages in rural emergency departments, which contributes to emergency department closures, the measures do not provide for a sustained increase in emergency department staffing across the Province. From 2017-18 to 2019-20, emergency department wait times were significantly lower despite higher patient volumes. As a result, Ontario’s success in addressing emergency department strain depends on the success of the Province’s measures for the fifth area of focus, which is expanding the health sector workforce.

Second, to achieve its target, the Province must permanently free up all 2,000 beds occupied by ALC patients waiting for a long-term care placement as of September 2022. This will be challenging given that there are over 39,000 Ontarians on the waitlist for long-term care and the Province must effectively reduce time to placement from hospitals from a median of 39 days to zero.

The Province is implementing a number of measures to increase the supply of nurses and personal support workers, including measures targeting pay, training and regulatory barriers. These measures have been announced across several policy documents.[4]

Based on the FAO’s analysis, the health workforce policy measures announced by the Province, along with natural growth, are expected to add 53,700 nurses and PSWs over the six-year period to 2027-28. Nevertheless, this increase in nurses and PSWs will not be sufficient to address current staffing shortages and meet Ontario’s commitments to expand care in hospitals, long-term care and home care, with an expected shortfall of 33,000 nurses and PSWs in 2027-28.

Failure to address the projected shortfall in nurses and PSWs will result in the Province being unable to meet its expansion commitments in hospitals, home care and long-term care. The shortfall will also have additional impacts on health sector service levels, including in hospital emergency departments, the waitlist and wait times for surgeries, and average hours of direct care provided to long-term care residents.

This report reviews the Province’s health sector spending plan in the 2022 Ontario Budget, the 2022-23 Expenditure Estimates, and the 2022 Ontario Economic Outlook and Fiscal Review (known as the Fall Economic Statement or FES). Health sector spending includes the combined spending by the Ministries of Health and Long-Term Care.

For the current fiscal year, 2022-23, the FAO estimates that the Province has allocated $1.3 billion in excess funds that are not required to support existing programs and announced commitments.

However, beginning in 2023-24, the FAO projects health sector funding shortfalls, starting at $1.6 billion in 2023-24 and growing to $6.0 billion in 2027-28.

The FAO projects that in order to return to pre-pandemic vacancy rates and meet government program expansion commitments in hospitals, home care and long-term care, Ontario needs 86,700 additional nurses and personal support workers by 2027-28. This represents an approximately 26 per cent increase in nurses and a 45 per cent increase in personal support workers employed in these sectors.

In 2022-23, the FAO’s projection for health sector spending is $1.3 billion lower than the Province’s spending plan. This is primarily due to the FAO’s lower projected COVID-19-related spending. However, by 2024-25, the FAO’s spending projection is $4.6 billion higher than the Province’s. Most of the spending gap is in the hospitals and OHIP (physicians and practitioners) program areas, which are the two largest health sector spending categories.[6] Overall, the FAO projects 3.1 per cent average annual spending growth between 2021-22 and 2024-25. In contrast, the Province projects slower growth, averaging 1.1 per cent from 2021-22 to 2024-25.

Recovery Period: The Province plans to increase annual health sector spending by an average of 3.9 per cent per year over the recovery period from 2024-25 to 2027-28. In comparison, based on the FAO’s review of health sector programs and announced commitments, the FAO projects spending will grow at an average annual rate of 4.2 per cent over the same period. As a result, the FAO projects that health sector spending will be $6.0 billion higher in 2027-28 compared to the government’s forecast in the 2022 budget.

For the period between 2021-22 and 2027-28, the FAO projects health sector spending will grow at an average annual rate of 3.6 per cent. The FAO projects that spending on the two largest program areas, hospitals and OHIP (physicians and practitioners), will grow by average annual rates of 3.0 and 4.1 per cent, respectively. Ontario public drug programs spending is projected to grow by an average of 5.7 per cent per year, followed by mental health and addictions programs (5.4 per cent) and community programs (5.0 per cent). The FAO projects that the long-term care program area will have the highest average annual growth rate over the six-year period, at 8.3 per cent, while other programs will decline by an average of -1.2 per cent per year due to the expiry of time-limited COVID-19-related spending. Lastly, spending on health capital is projected to grow at 3.1 per cent per year.

Given that there were significant time-limited investments related to the COVID-19 pandemic in 2021-22, and that the COVID-19 pandemic impacted service levels in many areas of the health sector, the FAO has also provided growth rates from 2019-20 to 2027-28 to provide a better indication of base health sector program spending growth. From 2019-20 to 2027-28, the FAO estimates base health sector spending will grow at an average annual rate of 5.0 per cent.

Program Area 2021-22 Actual Spending ($ billions) 2027-28 Projected Spending ($ billions) Average Annual Growth Rate (%) 2021-22 to 2027-28 Average Annual Growth Rate (%) 2019-20 to 2027-28 Hospitals 26.4 31.5 3.0 4.0

The two most significant factors behind the FAO’s spending projection are assumptions for hospital employee wage growth and hospital capacity.

The largest component of hospitals spending is compensation, which comprises approximately 60 per cent of total hospital operating expenses.

From 2022-23 to 2024-25, the FAO estimates hospital employee wages will grow at an average annual rate of 1.5 per cent. This growth rate is below the historical average due to the impact of Bill 124,[7] which limits base salary increases to one per cent per year for a period of three years.[8]

As collective agreements subject to Bill 124 expire, the FAO forecast assumes that wage growth will revert to the historical average of 2.4 per cent.

The FAO’s spending forecast for hospitals also reflects growth in hospital capacity, which is measured through the number of hospital beds. The FAO uses growth in hospital beds as a proxy for growth in the number of services provided by Ontario hospitals, which determines the required operating funding and staffing. Based on the FAO’s analysis of the Province’s hospital capacity expansion and infrastructure plans from the 2022 Ontario Budget, the FAO estimates that the number of hospital beds in Ontario will increase by 1,400 beds (4.0 per cent) from 2021-22 to 2027-28,[9] which will require approximately 10,000 additional hospital workers (includes nurses and personal support workers (see Chapter 5 for analysis) plus other hospital workers).

given recent elevated inflation, there is the potential for above-average wage settlements,[10] which would lead to higher than projected spending.

The government has appealed this decision. If the government is unsuccessful in its appeal, then the FAO estimates that provincial spending on wages for hospital employees could increase by an additional $3.6 billion over the six-year period to 2027-28.[11]

OHIP provides funding for more than 6,000 insured services to eligible Ontario residents from various providers, including physicians, hospitals, community laboratories, independent health facilities and other clinics.

The largest component of the OHIP program area is physician services, which comprises over 80 per cent of program area spending.

The FAO projects community programs spending will grow at an average annual rate of 5.0 per cent from 2021-22 to 2027-28.

Overall, the FAO estimates that the long-term care program area will have the highest spending growth in the health sector, at an average annual rate of 8.3 per cent from $6.8 billion in 2021-22 to $11.0 billion in 2027-28. This growth is primarily driven by the Province’s commitments to add 30,000 net new long-term care beds by the end of 2028, redevelop approximately 30,000 existing beds, and increase average hours of direct care provided to long-term care residents from a nurse or personal support worker from 2.75 hours in 2018-19 to four hours in 2024-25

The FAO projects other programs spending will decrease at an average annual rate of 1.2 per cent from 2021-22 to 2027-28. This decline in spending is the result of time-limited COVID-19-related spending in 2021-22. Removing the effect of time-limited spending, the FAO estimates other programs spending will grow by an average annual rate of 4.1 per cent from 2019-20 to 2027-28.

Health sector capital assets include approximately 913 buildings, totalling about 90 million square feet, as well as machinery and equipment (such as medical imaging machines and ventilators). The FAO projects 3.1 per cent average annual growth in health capital spending from 2021-22 to 2027-28. This projection is based on the amortization profile of hospital infrastructure assets and the Province’s 10-year infrastructure plan in the 2022 Ontario Budget.

In the 2022 Ontario Budget, the Province plans to invest $44.9 billion in health sector infrastructure over 10 years, including $40.2 billion for hospitals and $4.7 billion for other health sector infrastructure programs. The total 10-year health sector infrastructure investment plan represents an $11.2 billion increase from the 10-year plan in the 2021 Ontario Budget. Most of the 10-year infrastructure spending plan increase is for hospitals ($9.9 billion), with the remaining $1.3 billion increase for other health sector infrastructure programs.

If the $44.9 billion planned investment in health sector infrastructure is achieved, it would be a $13.6 billion (43.3 per cent) increase from the $31.3 billion health sector infrastructure investment over the previous 10 years from 2012-13 to 2021-22. On a real basis, the Province’s 10-year health infrastructure plan in the 2022 budget represents a smaller increase in spending on infrastructure compared to the previous 10-year period. After adjusting for inflation, the Province spent $36.7 billion over the previous 10 years (in 2021 dollars) and plans to spend $40.7 billion (in 2021 dollars) over the next 10 years. Therefore, in real terms, the 10-year health sector infrastructure spending plan in the 2022 budget represents a $4.0 billion (10.8 per cent) increase in investments compared to the previous 10-year period.

In 2005, the Province had approximately 31,865 hospital beds. Over the next 14 years, the Province added 830 hospital beds, an increase of 2.6 per cent, while Ontario’s population increased by 16.1 per cent and the population of Ontarians aged 65 and older, who occupy over 50 per cent of hospital bed days, grew by 56 per cent.

In addition, a growing proportion of existing hospital bed capacity is being occupied by patients waiting to go elsewhere. Limited growth in health sector capacity outside of hospitals, especially in long-term care homes, is contributing to alternate level of care (ALC) patients occupying more hospital beds. A patient is designated as ALC when they no longer need the level of care they are receiving in hospital but continue to occupy a hospital bed while waiting to go elsewhere such as a long-term care home or rehabilitation facility. Between 2012-13 and 2019-20, the share of hospital capacity occupied by ALC patients increased from 13.3 per cent to 17.0 per cent.

From 2017-18 to 2019-20, the average occupancy rate for Ontario’s hospitals was 96 per cent, while each year an average of 42 hospitals reported average occupancy rates for acute care beds of over 100 per cent. High hospital occupancy rates contribute to “hallway health care” with approximately 1,000 patients receiving care in hallways or other unconventional spaces on any given day from 2017-18 to 2019-20.

More recently, in 2020-21 and 2021-22, Ontario had fewer hospitalizations than in either of 2018-19 or 2019-20, due to the COVID-19 pandemic.[21] This resulted in lower overall occupancy and fewer patients receiving care in hallways or other unconventional spaces. However, in the first quarter of 2022-23, occupancy rose to 93 per cent, which is close to the pre-pandemic average, and nearly 1,300 patients received care in hallways or other unconventional spaces on any given day, which is the highest number since the Province started collecting this data in 2017.

In addition to growing numbers of patients receiving care in hallways or unconventional spaces, capacity pressures are manifesting in other hospital functions. For example, wait times for a hospital bed for patients admitted from the emergency department are currently the longest in over 15 years.[22] Finally, capacity pressures can result in hospitals being unable to respond to surges in demand. For example, in November 2022, the Province reported no available paediatric ICU beds for a 12-day period due to the unusual influenza (flu) and respiratory syncytial virus (RSV) seasons.[23]

Overall, the Province plans to add 3,000 net new hospital beds from 2021-22 to 2031-32 through its 10-year hospital infrastructure plan, of which the FAO estimates that 1,400 new hospital beds will be in operation by 2027-28. In addition, the Province has announced that it will continue to fund the operation of beds in hospitals and alternate health facilities that were added in response to the COVID-19 pandemic. The FAO estimates the continuation of these beds will increase hospital capacity by approximately 3,100 beds. Combined, the FAO estimates that hospital bed capacity will increase by approximately 4,500 beds from pre-pandemic levels to the end of the forecast period, from 32,696 beds in 2019-20 to 37,224 beds in 2027-28. This represents a 13.8 per cent increase in hospital beds over the eight-year period, compared to the 2.6 per cent increase in hospital beds over the 14-year period from 2005 to 2019.

Note: Alternate Health Facility refers to beds in alternate health facilities such as retirement homes that are available to hospitals to meet surges in patient demand.

As of September 2022, approximately 5,000 ALC patients were waiting in Ontario hospitals for care elsewhere. Of those patients, about 2,000 were waiting for a long-term care bed and 540 were waiting for home care.

Bill 7 allows hospital patients designated as ALC to be assessed for eligibility for long-term care, discharged from hospital, and admitted to a long-term care home that was not selected by the patient or their substitute decision maker. While patients cannot be physically transferred without consent, hospitals are required to charge discharged patients a fee of $400 every 24 hours that they remain in the hospital.[26] ALC patients can be sent to any appropriate long-term care home within 70 kilometres of their preferred location in southern Ontario and 150 kilometres in northern Ontario.

The second area of focus, which the FAO assumes is intended to free up 500 beds,[27] is through increased funding for community care so that ALC patients waiting for home care can leave the hospital faster.[28]

First, with respect to the 4,500 beds that the Province plans to add by 2027-28, as outlined in Chapter 3, the FAO estimates that the Province has not allocated sufficient funding to the health sector. To ensure the 4,500 additional hospital beds can be operated, the Province must increase funding to the health sector beginning in 2023-24.

Second, to free up 2,500 existing beds occupied by ALC patients, the Province will need to place all 2,000 ALC patients waiting for a long-term care bed, as of September 2022, and permanently free up those hospital beds for other patients. There are over 39,000 Ontarians on the waitlist for long-term care and, in September of 2022, the median wait time for hospital ALC patients discharged to long-term care was 39 days. To free up all 2,000 beds occupied by ALC patients waiting for a long-term care placement, the Province must effectively reduce time to placement from hospitals from 39 days to 0 days. Bill 7 does give patients in hospitals waiting for a long-term care bed priority over patients waiting in the community,[29] however, a space must still be available for the patient and the long-term care home must have the necessary supports to meet the patient’s care needs. Compounding this issue is that patients that wait the longest in hospitals for long-term care tend to have specialized needs and support requirements that are not offered in all long-term care homes.[30] Overall, as of December 2022, the Province had reduced the number of beds occupied by ALC patients waiting for long-term care by 350.[31] However, this means that the Province must permanently free up an additional 1,650 beds occupied by ALC patients waiting for a long-term care bed to achieve its target. For the reasons stated above, the FAO expects that this will be unlikely.

Finally, even if the Province succeeds in increasing available hospital capacity by 7,000 beds, that will not be sufficient to serve the growth in demand for hospital services from Ontario’s growing and aging population. From 2019-20 to 2027-28, the FAO estimates that Ontario’s population will increase by 12 per cent, while the number of Ontarians aged 65 and over will increase by 30 per cent. In total, the FAO estimates that this population growth and aging will increase demand for hospital services by 21 per cent.[32] As a result, the Province would need to increase available hospital capacity by 7,500 beds just to meet the projected growth in demand for hospital services from 2019-20 to 2027-28.

Therefore, even if the Province achieves its plan to add 4,500 new hospital beds and free up 2,500 existing beds, it will still be 500 beds short of the estimated 7,500 beds needed just to serve the growth in demand for hospital services from 2019-20 to 2027-28. This suggests that without additional measures, Ontario will have less available hospital capacity relative to need in 2027-28 than in 2019-20.

On average, older Ontarians use more health resources than younger Ontarians. Although the average Ontarian benefits from $4,900 of health care spending per year, Ontarians aged 65 to 69 benefit from $7,500 of health care spending per year on average, while Ontarians aged between 75 and 79 benefit from $11,900, and Ontarians over the age of 90 benefit from $29,600.

In 2021-22, the per diem cost of home care in Ontario was $36, which was significantly less than long-term care at $151 or a hospital bed at $722.

From 2012-13 to 2019-20, the number of nursing and personal support services provided by home care programs grew by 34 per cent, which is higher than the 27 per cent growth in Ontario seniors (aged 65 and over), who receive the majority of home care services.

n 2021, 6.3 per cent of Ontarians received formal home care services, which is higher than the Canadian average of 6.1 per cent

Also, in 2020-21, the median wait time for home care in Ontario was two days, which was either below or tied with all other reporting provinces and territories.[34]

However, over the same time period, the Province did not make a similar investment in long-term care to match the expansion of home care. In 2011-12, the Province had 78,053 long-term care beds. Over the next eight years, the Province added 87 long-term care beds, an increase of 0.1 per cent, while the population of Ontarians aged 75 and older, who occupy over 80 per cent of long-term care beds, grew by 24 per cent.

This limited growth in the number of long-term care beds has led to long wait times and waitlists for long-term care. As of November 2022, over 39,000 Ontarians were on the waitlist for a long-term care placement and the median wait time for a long-term care bed was 126 days

Looking ahead, the number of Ontario seniors (aged 65 and over) is projected to increase by 22 per cent from 2021-22 to 2027-28. This will significantly increase demand for home care and long-term care services. The Province’s plan to preserve hospital capacity and ensure Ontario seniors can access care in the appropriate setting involves significant investments to expand the capacity of both home care and long-term care.

The FAO estimates that the new funding will result in home care spending growth averaging 6.7 per cent per year, from $2.9 billion in 2019-20 to $4.0 in 2024-25

This spending growth will increase the number of nursing and personal support hours by 18 per cent from 2019-20 to 2024-25.

Overall, the FAO estimates that the Province’s home care expansion will increase the number of Ontarians aged 65 and over who receive home care services from 410,000 in 2019-20 to 485,000 in 2024-25.

However, over the same time period, the FAO estimates that the number of Ontarians aged 65 and over will also increase by 18 per cent. This means that by 2024-25, the number of funded hours for nursing and personal support services per Ontarian aged 65 and over will be 17.5, the same level as in 2019-20.

The FAO estimates that these two commitments will result in average annual long-term care program spending growth of 12.2 per cent from 2019-20 to 2027-28. This growth is significantly higher than the average annual growth of 2.4 per cent from 2011-12 to 2019-20.

In 2019-20, Ontario had approximately 78,200 long-term care beds. The FAO estimates that the number of beds will increase to approximately 105,000 by the end of 2027-28.[37] From 2019-20 to 2027-28, the number of long-term care beds will increase by 34 per cent. This growth in long-term care capacity is significantly higher than the 0.1 per cent growth from 2011-12 to 2019-20.

However, between 2019-20 and 2027-28, the FAO estimates that the number of Ontarians aged 75 and over will increase by 37 per cent compared to the projected 34 per cent increase in the number of beds. Therefore, despite the significant increase in the number of long-term care beds by 2027-28, the FAO estimates that Ontario will still have fewer beds per Ontarian aged 75 over in 2027-28 than it did in 2019-20.

For home care, the number of nursing and personal care hours per Ontarian aged 65 and over will be about the same in 2024-25 as it was in 2019-20. For long-term care, the number of beds per 1,000 Ontarians aged 75 and over will decline slightly from 71 in 2019-20 to 70 in 2027-28.

In response to the COVID-19 pandemic, the Province issued directives to pause elective surgical procedures[39] three times to preserve hospital capacity. These directives were issued on March 15, 2020, April 9, 2021 and January 5, 2022, with each lasting between five and 10 weeks.

Largely as a result of the directives to pause elective surgical procedures, and also due to the impact of the COVID-19 pandemic on hospital operations, 398,000 fewer surgeries were performed in the 2020 to 2022 period than would have occurred if 2019 surgical volumes had been maintained. This represents an average 20 per cent reduction in surgery volumes each year, with reductions of 187,500 (29 per cent) in 2020, 117,100 (18 per cent) in 2021 and 93,800 (14 per cent) in 2022.[40]

Although 398,000 fewer surgeries were performed over three years, from 2020 to 2022, the surgery waitlist only increased by 50,000. As of September 2022, approximately 250,000 patients were on waitlists for surgical procedures, which is 50,000 more patients than the pre-pandemic level of 200,000.

As of September 2022, of the total surgery waitlist of 250,000, approximately 107,000 (43 per cent) were long-waiters, up from an average of 38,000 (20 per cent) long-waiters on the surgery waitlist before the COVID-19 pandemic.

With a 50,000 patient increase in the surgery waitlist and fewer surgeries being performed, the implied average wait time for surgeries has increased. In 2019, the average wait time for surgery was 3.7 months. In 2022, the average wait time was 5.5 months, a 48 per cent increase from 2019.[41]

To help achieve these targets, the Province has provided premium pricing incentives to hospitals to increase surgical volumes. The Province has also provided funding to increase the number of procedures performed at paediatric and private hospitals, and independent health facilities. In total, the Province has allocated $858 million for surgical recovery from 2020-21 to 2022-23, $326 million of which is allocated in 2022-23.

Of this $858 million, approximately $603 million has been allocated to increase surgical volumes and increase the number of surgeries done after hours at hospitals, as well as for additional operating hours for MRI and CT machines. An additional $37 million has been allocated to paediatric and private hospitals, and to independent health facilities for OHIP-covered surgeries and MRI/CT hours. The remaining $218 million has been allocated to a variety of measures that include training, supplies and equipment.

Despite the Province’s $858 million investment over three years, the number of surgeries performed has not returned to pre-pandemic levels. Looking only at months not affected by elective surgery pauses, the average number of surgeries performed in each month from 2020 to 2022 was significantly lower than in 2019, with average monthly surgeries performed 14 per cent lower in 2020, 12 per cent lower in 2021 and eight per cent lower in 2022 (as of September 2022).

Monthly surgical volumes in 2022 remained below 2019 levels due to the on-going impact of COVID-19 and the impact on hospital operations from the unusual influenza (flu) and respiratory syncytial virus (RSV) seasons.[42] Staffing shortages have also caused hospitals to ramp down the number of surgical procedures (see section E).[43]

The reason the surgery waitlist has increased by only 50,000, when 398,000 fewer procedures were performed from 2020 to 2022 as compared to 2019 levels, is that fewer Ontarians were added to the surgical waitlist compared to pre-pandemic levels. For example, from March 2022[44] to September 2022, an average of 51,500 Ontarians were added to the surgical waitlist each month. This is 13 per cent lower than the average of 59,100 patients added to the surgery waitlist each month from March to September of 2019. This 13 per cent decline in monthly waitlist additions from March to September of 2022 is greater than the eight per cent decline in monthly surgeries performed over the same period.[45]

The growth in the waitlist occurred mostly during the second and third directives to pause elective procedures where the reduction in diagnostic imaging and primary care was not as significant. Outside the periods when elective surgeries were paused, the number of surgeries performed has outpaced waitlist additions and the Province has been able to gradually reduce the waitlist. For example, following the end of the last directive to pause surgeries in March 2022, the waitlist has been gradually reduced from 263,000 in March of 2022 to approximately 250,000 in September of 2022.

As of September 2022, the most recent complete data available to the FAO, the surgery waitlist was 250,000 patients.[46] The Province’s target is to reduce the waitlist to 200,000 by March 2023. To achieve this target, the rate of decline in the waitlist would need to be significantly faster than what the Province has achieved up to September 2022.

After pauses of elective surgeries in 2021 and 2022, the waitlist has been reduced by an average of 2,280 patients per month. Assuming no further interruptions, similar volumes of surgeries being performed and similar volumes of patients being added to the waitlist, the Province would reduce the surgical waitlist back to 200,000 patients by July 2024. This would be 16 months later than the Province’s target of March 2023.

As of September 2022, the number of patients on the surgery waitlist classified as long-waiters was 107,000, which was the highest number recorded since the start of the pandemic. Consequently, without additional measures, the Province will not achieve its goal of reducing the number of patients on the surgery waitlist classified as long-waiters to the pre-pandemic level of 38,000.

In 2021-22, Ontario emergency departments saw an average of 445,000 visits per month which is only nine per cent below typical volumes. From April to November in 2022-23, there was an average of 482,000 emergency department visits per month, which is about one per cent below typical volumes.[48

In 2022-23, the average length of stay in an emergency department for all patients was approximately 6.1 hours.[50] This is 30 per cent higher than wait times over the five-year period prior to the COVID-19 pandemic and is also the longest average wait time recorded in over 15 years.

The FAO estimates 143 of the 145 emergency department closures have occurred in small population centres with populations of less than 30,000.[55] For perspective, about 40 per cent of emergency departments in Ontario are in small population centres and those emergency departments represent 99 per cent of all emergency department closures.

From 2017-18 to 2019-20, emergency department wait times were significantly lower despite higher patient volumes and wait times for Ontario emergency departments were below the Canadian average in each year.[57] Even looking at hospitals with the longest wait times in 2022, for the most part, those hospitals have lower patient volumes than before the COVID-19 pandemic. Of the 20 hospitals with the longest emergency department wait times for admitted patients in 2022-23, 17 have lower patient volumes than the 2017 to 2019 average. This suggests that the more pressing immediate problem is emergency department staffing as opposed to patient volumes/demand. However, the Province’s emergency department staffing measures only provide hospitals with flexibility to deal with short-term issues. The measures do not provide a sustained increase in emergency department staff.

Since the start of the COVID-19 pandemic, health sector job vacancies have more than doubled in Ontario from 14,800 in the fourth quarter of 2019 to 34,800 in the third quarter of 2022. These vacancies are a result of the number of positions in the health sector growing faster than the number of workers.

In the third quarter of 2022, there were 14,575 vacant nursing positions representing a vacancy rate of eight per cent, while there were 12,300 vacant personal support worker (PSW) positions representing eight percent of all PSW positions. To return to pre-pandemic vacancy rates,[58] the FAO estimates that 9,700 nurses and 7,700 PSWs are needed.

Furthermore, the FAO estimates that about 23,800 additional nurses and 44,100 additional personal support workers will be needed in hospitals, long-term care and home care by 2027-28 to meet government program expansion commitments. These commitments include adding approximately 1,000 new hospital beds from 2022-23 to 2027-28 (see section A for details), expanding home care (see section B for details), and creating 30,000 new long-term care beds and increasing direct care hours for residents in long-term care homes (see section B for details).

While wage data is not available specifically for personal support workers, in 2022, weekly average earnings in Ontario long-term care facilities were 1.3 per cent below the national average, despite the Province’s $3 per hour wage increase for PSWs in long-term care, first introduced in October 2020 (see chapter 4), and Ontario’s higher cost of living.[62]

Based on the FAO’s analysis, the Province’s key measures to increase nursing employment are accelerating the registration of internationally educated nurses and increasing nursing student enrolment. The registration of internationally educated nurses (IENs) is being achieved primarily by relaxing regulatory barriers to registration, including Ontario work experience requirements and language testing requirements. The registration of IENs is also being supported by the establishment of the temporary registrant class, timeliness for processing of applications, expansions of the Supervised Practice Experience Partnership (SPEP) Program, and temporary coverage of professional fees. Lastly, the Province temporarily increased nursing enrolment by 2,000 spaces in 2021-22 and has committed to permanently increase nursing enrolment by 1,500 seats in 2023, consisting of spaces for 500 registered practical nurses and 1,000 registered nurses.

The Province’s key measures to increase personal support worker employment are grants to students and wage increases. In 2021-22, the Province committed to spend up to $200 million to train up to 16,200 personal support workers through publicly assisted colleges, private career colleges and school boards. From this overall funding, the Province committed $115 million to train up to 6,000 PSWs over six months at public colleges starting in April 2021[64] and $86 million to train up to 8,000 new PSWs at private career colleges and school boards in 2021-22.[65] Subsequently, the Province announced $54.7 million to train up to 4,000 new PSWs at private career colleges in summer 2022.[66] Regarding wage increases, in October 2020, in response to the COVID-19 pandemic, the Province temporarily increased wages for personal support workers by $3 per hour in home care and long-term care and $2 per hour in hospitals. In 2022, these wage increases were made permanent (see chapter 4).

The FAO estimates that 34,800 more nurses will be required by 2027 but only 31,900 will be added, resulting in a shortfall of 2,900 nurses. Over the next three years, the shortage will average approximately 10,000 nurses, and then gradually decline as growth in demand for nurses from long-term care and hospitals slows, and the incremental graduates from increased enrolment start to enter the labour market.

Based on the FAO’s analysis, the shortage of nurses will continue across the forecast period.

Measures to accelerate the registration of internationally trained nurses have had success to date. In 2022, Ontario registered 5,125 new internationally educated nurses, up from an average of 1,411 per year from 2015 to 2019. However, some of this success was due to a backlog in active applications, which reached 14,880 in 2020. Without new measures to increase the immigration of nurses to Ontario, the FAO assesses that maintaining the 2022 increase in registrations will be challenging. Given this, the FAO assumes that Ontario will add 3,600 incremental internationally educated nurses until 2024 then, starting in 2025, the FAO assumes that Ontario will continue to register a more sustainable 2,000 incremental internationally educated nurses each year.

As noted above, the Province provided funding for a temporary 2,000 student increase in nursing enrolment in 2021-22, consisting of spaces for 1,453 registered practical nurses and 551 registered nurses. The Province has also committed to permanently increase nursing enrolment by 1,500 seats in 2023, consisting of 500 spaces for registered practical nurses and 1,000 spaces for registered nurses.[67] Increased enrolment is forecasted to add 4,100 nurses over our projection period.[68]

In addition to policy measures, nursing employment will experience natural growth. Natural growth reflects the ongoing net effect of factors that add to the supply of nurses (e.g., graduations and immigration) and factors that detract from the supply of nurses (e.g., emigration, exits to other careers and retirements). The FAO estimates that natural growth will add a net 2,400 nurses each year for hospitals, home care and long-term care, consistent with pre-pandemic trends.

In short, as of the writing of this report, the FAO projects that the health workforce policy measures announced by the Province, along with natural growth, will add 53,700 nurses and PSWs over the six-year period to 2027-28. Nevertheless, this increase in nurses and PSWs will not be sufficient to address current staffing shortages and meet Ontario’s commitments to expand care in hospitals, long-term care and home care, with an expected shortfall of 33,000 nurses and PSWs in 2027-28.

Based on a recent survey of 100 not-for-profit LTC homes, 44 per cent report that they are unsure whether they will meet the government’s target of four hours of daily direct care by 2024-25 due to staffing shortages and higher fees charged by temporary staffing agencies.[71]

Academic literature predicts that health care staffing shortages result in adverse outcomes for patients, including more infections, more pressure injuries, more patient falls and higher mortality.[72] For nurses, understaffing contributes to increased stress, increased dissatisfaction and ultimately increased turnover.[73]

However, the FAO also projects that without additional measures, there will be a shortfall of 33,000 nurses and PSWs in 2027-28. In order to address this shortfall, the Province may have to introduce new measures that would increase spending above the FAO’s health sector spending outlook. For example, such measures could include increasing wages, reducing workloads, structuring staffing to use more desirable full-time positions, increasing reliance on agency workers and private providers not subject to wage restraints, and/or adding new funding for education or training.

The FAO’s analysis assumes that natural growth in the number of nurses and PSWs in hospitals, home and community care, and long-term care will follow historical trends, but certain factors could lead to a lower than historical increase. There are some indications that hospitals are facing challenges retaining nurses due to low job satisfaction from burnout and low wage growth. Consistent with this, the Ontario Hospitals Association reported 14.5 per cent turnover in 2021-22 compared with 8.4 per cent in 2019-20.[74] As noted above, in 2022, wages for Ontario nurses were the lowest in Canada, while wages for workers in Ontario long-term care facilities were below the Canadian average.

For clarity, totals reflect the number of workers required to restore and maintain normal staffing levels in the hospitals, home and community care, and long-term care program areas, while meeting the government’s program expansion commitments in these areas. The FAO’s projection for the number of nurses and personal support workers required to be hired does not reflect an assessment about the quality of services that should be provided by these program

Ontario’s economy has remained resilient in the face of ongoing uncertainty, with real gross domestic product (GDP) estimated to have increased by 3.7 per cent in 2022.

The increased revenue forecast reflects stronger than expected taxation revenues as a result of higher net tax assessments for 2021 and prior years, based on new information received from the Canada Revenue Agency since the release of the 2022 Ontario Economic Outlook and Fiscal Review.

Other program expense increases since the release of the 2022 Ontario Economic Outlook and Fiscal Review include: spending related to reopening of colleges and its resulting additional on-campus activity; the government’s commitment to support the City of Toronto, to address a portion of its 2022 operating deficit; and additional funding for prevention and containment of COVID-19 at long-term care homes. These expenses have been partially offset by additional third-party revenues from colleges, ministry underspending, particularly for infrastructure projects, and through the drawdown of existing contingencies within the fiscal plan.

Interest on debt is projected to be $13.4 billion, slightly lower than the $13.5 billion forecast in the 2022 Budget and approximately $0.2 billion lower than the $13.6 billion projection in the 2022 Ontario Economic Outlook and Fiscal Review,due to a lower deficit than previously estimated partially offset by higher than forecast interest rates.

As a result of the lower deficit, the net debt-to-GDP ratio is projected to be 38.3 per cent in 2022–23, 3.1 percentage points lower than the 41.4 per cent forecast in the 2022 Budget

The 2022 Budget included a $1.0 billion reserve in 2022–23, to protect the fiscal outlook against any unforeseen changes in the province’s revenue and expense forecasts. This reserve has been maintained as part of the current fiscal outlook. It provides additional prudence in the government’s fiscal framework and is distinct from contingency funds that set aside dedicated funding to be allocated in response to emerging needs

The forecast for Total Taxation Revenue increased by $8.7 billion, compared to the 2022 Ontario Economic Outlook and Fiscal Review. Key changes in the taxation revenue outlook, compared to the 2022 Ontario Economic and Fiscal Review, include:Corporations Tax revenue increased by $5.0 billion, mainly due to higher amounts from processing 2021 and prior year tax returns by the Canada Revenue Agency;Sales Tax revenue increased by $3.4 billion, largely due to an upward revision by the federal government, in December of 2022, to Ontario’s 2021 HST official entitlements;Personal Income Tax revenue increased by $0.5 billion, mainly due to higher compensation of employees growth for 2022, reflecting strong growth in employment;Land Transfer Tax is $233 million lower, reflecting slowing activity in the housing market; andAll Other Taxes combined increased by $83 million, mainly due to higher revenues from the Gasoline Tax and Education Property Tax, partially offset by lower revenues from the Employer Health Tax, Ontario Health Premium and Fuel Tax.

$5.0 billion in one-time expense associated with ongoing land and land related claims with Indigenous communities, where Ontario is in active negotiations, or claims are accepted for negotiation or are under review;

$183 million to help long-term care homes prevent and contain the spread of COVID-19, including increased staffing supports;

$1.7 billion in program expense changes have been offset from contingencies.

The Ministry of Finance estimates that Ontario real GDP increased 3.7 per cent in 2022, which is higher than the 2022 Ontario Economic Outlook and Fiscal Review planning assumption of 2.6 per cent. Ontario nominal GDP is estimated to have increased 9.4 per cent in 2022, slightly above the 2022 Ontario Economic Outlook and Fiscal Review planning assumption of 9.2 per cent.

Private sector forecasters, on average, project Ontario’s real GDP to rise by 0.3 percent in 2023, compared to the 2022 Ontario Economic Outlook and Fiscal Review planning assumption of 0.5 per cent. Ontario’s nominal GDP is projected to rise by 2.9 per cent in 2023, compared to the 2022 Ontario Economic Outlook and Fiscal Review planning assumption of 3.5 per cent, due largely to weaker GDP inflation expectations.

Health (Total)68,414.468,414.4–COVID‑19 Health Responsefootnote 5[5]4,753.64,922.3168.7

Long-Term Care (Total)footnote 7[7]6,750.96,750.9

reasury Board Secretariat — Operating Contingency Fund4,325.81,529.1(2,796.7)Treasury Board Secretariat — Capital Contingency Fund224.2220.9(3.3)

Population — July (000s)footnote 16[16]14,30914,54514,72614,80915,109

In response to COVID-19, many surge capacity initiatives were put in place to help control health workforce overtime requirements. In the early days of the pandemic, many non-urgent procedures and surgeries were postponed to accommodate COVID-19–related care in hospitals.Reference 

During this time, data suggests that hospitals relied more on agency staff to fill gaps than in years prior: in 2020–2021, these workers logged 13.7 million hours, a 5.5% increase from the previous year.

Overtime hours among health care workers have been linked to decreases in physical and mental health and well-being, which can have long-term implications for the health of the health workforce and for health service delivery.

Among nurses not intending to retire, almost 1 in 4 (24.4%) intended to leave their job or change jobs in the next 3 years

Data on vacancy rates in Canada shows that in the fourth quarter of 2021 (October to December), job vacancies in the health care and social assistance sector reached an all-time high of 126,000, almost double the number of vacancies seen 2 years prior (64,000).

Hospitals and nursing and residential care facilities had the largest increases in job vacancies during this period compared with other sub-sectors.

The recent survey on the experiences of health care workers during the COVID-19 pandemic Reference 6 found that about 2 out of 5 PSWs (41.5%) reported feeling more stressed than before the pandemic. 82.5% indicated that the pandemic caused them to experience difficulties in a range of interpersonal, health and financial areas including balancing caregiving responsibilities, meeting financial obligations and emotional distress. Among those intending to leave or change jobs in the next 3 years, 37.7% reported stress or burnout as the primary reason.

“We’d like to direct you to her comments from the same day as the request,” a spokesperson for Jones’ office said. “The Minister has been clear all along, Ontarians will continue to use their OHIP card to access health care.”Jones made several references to OHIP on Aug. 11 — the day after Global News submitted its freedom of information request — but specific wording about privatization was not used.

“No, no, no — OHIP cards are used in the province of Ontario to fund publicly funded health-care systems,” Jones also said on Aug. 11. “That will continue under our watch… we will continue to fund OHIP services through our health care system.”

“The house binder is basically a massive cheat sheet for ministers going in question period or during debate,” said Ashley Csanady, a senior consultant for McMillan Vantage and a former Ontario Liberal staffer and journalist.

In July, during her orientation as Minister of Health, Jones met with a private hospital. Her calendar, which was also obtained through a freedom of information request, lists a meeting with Clearpoint Private Hospital.

Another talking point also appears to have been axed.“I want to be clear, there has been no expansion to the number of private hospitals who offer publicly funded procedures in Ontario,” the original note said.

The word “publicly” was scrubbed out and replaced by the handwritten word “OHIP.” The entire talking point was scored out.

“In this, it looks to me as if there was a set of messaging that was being proposed as very definitive, ‘We will not increase any private role for health care in Ontario,'” Csanady said.“And that made it as far as the binder and then someone — maybe the minister herself, maybe the chief of staff, maybe the director of communications — said that is too far.”

On Aug. 18, Ontario unveiled a five-point plan to tackle delays, staffing shortages and backlogs within the province’s struggling health-care system.To reduce wait times, the province decided to look at increasing “surgeries in paediatric hospitals and existing private clinics covered by OHIP.”That change was announced eight days after the health-care innovation talking points were drafted for Jones to repeat in the legislature.

The photocopy obtained by Global News shows several changes were made to a page entitled “Innovation in Ontario’s Hospitals,” which says it was updated on Aug. 10 within the minister’s house binder.

The binder also includes several messages apparently curated on March 31 for then-Minister of Health Christine Elliott to push back against a campaign by the Ontario Health Coalition accusing the Ford government of privatizing the province’s health care.

“This government is focused on building a better and more robust publicly funded health care system for the future,” one line says.Another adds, “A new license for a private hospital in Ontario has not been issued since 1973.”Neither line was edited or annotated in the photocopy obtained by Global News.

The Ontario Health Coalition launched a campaign, including lawn signs, to fight against “the Ford government’s unprecedented health care privatization plans.”

In an August sit-down interview with Global News, the CEO of Ontario Health said the private sector has historically operated independently in Ontario and suggested the continuation of that system could lead to additional poaching.

“We’ve got to be careful about this, and we can’t be taking from the public system over into the private system. It’s a zero-sum game,” Matthew Anderson told Global News.

Jones has said Ontarians shouldn’t be “afraid of innovation.”

Anderson pushed back on the assertions of privatization and said that’s not what Ontario Health is advocating for.

“If my family hears ‘privatization’ their mind will likely go to funding. They will be concerned that they now have to pay out of pocket to get access to something. And the premier has made that clear, we’re not talking about additional private-funded services,” Anderson said.

About 1.4 million Canadian adults indicated they had symptoms at least three months after a positive COVID-19 test or suspected infection

Of those who indicated a previous positive test or a suspected infection for COVID-19, 14.8% experienced symptoms at least three months after their infection. This translates into about 1.4 million Canadian adults or 4.6% of the Canadian population aged 18 years and older. A higher percentage of women (18.0%) reported prolonged symptoms compared with men (11.6%). No significant differences by age group were found in the percentage of Canadian adults reporting prolonged symptoms

Canadians with symptoms at least three months after an initial or suspected infection indicated that fatigue (72.1%) was the most reported unresolved symptom, followed by cough (39.3%), shortness of breath (38.5%) and brain fog (32.9%).

Among Canadian adults who rated their symptoms as severe at the time of their first positive test or suspected infection, 36.4% indicated having symptoms at least three months after their infection. As indicated by Chart 1, the percentage who indicated longer-term symptoms decreased as the severity of their initial symptoms decreased. Among those who rated the symptoms as moderate, 15.0% reported longer-term symptoms, while 6.3% who reported a mild case of COVID-19 reported longer-term symptoms.

The provisional results of the CCAHS are showing that among Canadian adults who indicated a positive test or suspected infection before December 2021, 25.8% had symptoms at least three months after their infection. For those indicating an infection experienced in December 2021 or after, the percentage that had symptoms at least three months after infection decreased to 10.5%.

Of Canadian adults who reported symptoms at least three months after being infected, 32.5% had recovered from their initial symptoms before symptoms returned. A higher percentage of men (37.2%) than women (28.7%) indicated their symptoms had resolved and then returned.

The Province’s $193.0 billion spending plan includes $4.6 billion in unallocated funds in the Contingency Fund. As of the end of the first quarter, there were no transfers from the Contingency Fund to government programs.

Most sectors spent less than planned, led by ‘other programs’ ($889 million or 14.3 per cent under plan), education ($195 million or 3.2 per cent under plan) and postsecondary education ($146 million or 9.0 per cent under plan).

Three sectors spent more than planned: health ($319 million or 1.8 per cent above plan), interest on debt ($176 million or 5.6 per cent above plan) and justice ($35 million or 2.7 per cent above plan).

Health spent $1,398 million (8.3 per cent) more in the first quarter of 2022-23 compared to 2021-22, largely due to higher spending on payments to physicians ($501 million) and public health ($341 million).

Although the Province expected to spend $40.7 billion in the first quarter of 2022-23, actual unaudited spending was $39.9 billion. This was $776 million (1.9 per cent) less than planned.

As of the end of the first quarter, June 30, 2022, the Province had not made any changes to its $193.0 billion spending plan.

For 2022-23, the Province expects to spend $40.7 billion in the first quarter, $43.5 billion in the second quarter, $44.7 billion in the third quarter, and $64.1 billion in the fourth quarter.[4]

Health sector spending: $319 million (1.8 per cent) above plan. Highlights include: $353 million above plan in Ontario Health Insurance (Vote-Item 1405-1), which administers payments to physicians. $203 million above plan in Health Capital Program (Vote-Item 1407-1), which provides capital funding to hospitals and other health care facilities. $200 million below plan in Health Services (Vote-Item 1416-1), which funds the operation of hospitals, home care, community services (mental health, health centres and support) and other services.

As noted above, in the first quarter of 2022-23, the Province spent $39.9 billion. This was $3.1 billion (8.3 per cent) more than was spent in the first quarter of 2021-22. All sectors spent more in the first quarter of 2022-23 compared to 2021-22. The largest year-over-year spending increase was in health ($1,398 million), followed by interest on debt ($480 million), education ($453 million), children’s and social services ($285 million), ‘other programs’ ($250 million), justice ($138 million) and postsecondary education ($51 million).

The health sector spent $1,398 million (8.3 per cent) more in the first quarter of 2022-23 compared to 2021-22, largely due to higher spending for: payments to physicians ($501 million); Population and Public Health (Vote-Item 1406-4) ($341 million); Major Hospital Projects ($191 million); Drug Programs (Vote-Item 1405-2) ($181 million); Home Care ($171 million); the operation of long-term care homes ($84 million); and Clinical Education ($72 million). offset by lower spending for: the Operation of Hospitals (-$106 million); and capital investments for long-term care homes (-$133 million).

Expected fourth quarter spending is significantly higher than expected spending in each of the first three quarters due to year-end accrual adjustments.

Additionally, an increase in critical staffing shortages was reported in over half of nursing homes and roughly half of seniors' homes.

Overall, 84% of nursing homes and seniors' homes reported that at least 95% of their residents were fully vaccinated and 86% reported that at least 95% of their employees were fully vaccinated.

Nursing care facilities are also commonly known as long-term care homes or nursing homes

Some hospitals also provide these services and were included in the analys

Community care facilities for the elderly are also known as seniors' homes. Seniors' homes are largely engaged in providing residential and personal care services for the elderly as well as persons who are either unable to fully care for themselves or who do not wish to live independently.

Overall program expense in 2022–23 is projected to be unchanged from the outlook presented in the 2022 Budget. New commitments announced since the release of the 2022 Budget will be funded through existing contingencies within the fiscal plan.

As a result of faster-than-expected nominal GDP growth and the lower deficit forecast than at the time of the 2022 Budget, the net debt-to-GDP ratio is projected to be 40.4 per cent in 2022–23, 1.0 percentage point lower than the 41.4 per cent forecast in the 2022 Budget.

The next steps in the government’s Plan to Build Ontario will be outlined in the 2022 Ontario Economic Outlook and Fiscal Review, to be released by November 15, 2022.

Revenues in 2022–23 are projected to be $1.2 billion higher than forecast in the 2022 Budget, mainly reflecting higher taxation revenues. The increase in taxation revenues is due to stronger 2022 nominal GDP growth expectations, as a result of higher-than-projected economy-wide inflation in 2022.

Overall program expense in 2022–23 is projected to be $185.2 billion, unchanged from the forecast in the 2022 Budget. New commitments announced since the release of the 2022 Budget will be funded through existing contingencies within the fiscal plan.

The $1.0 billion reserve has been maintained as part of the current fiscal outlook.

Notes: Numbers may not add due to rounding. Current outlook primarily reflects information available as of June 30, 2022.

The forecast for Total Taxation Revenue increased by $1.2 billion compared to the 2022 Budget, due to stronger nominal GDP growth reflecting higher-than-projected economy-wide inflation in 2022. The increase in nominal GDP is expected to be broad-based, impacting wages, consumer spending and corporate profits

As a result, the revenue projections for Personal Income Tax increased by $941 million, for Sales Tax by $597 million and for Corporations Tax by $417 million. These increases are partially offset by a $787 million decrease in Land Transfer Tax, due to slowing activity in the housing market.

Expectations for Ontario’s real GDP growth have also been revised lower. Among recent private-sector forecasts, the average projected real GDP growth for 2022 is 3.6 per cent, slightly lower than the 2022 Budget planning assumption of 3.7 per cent.

The 2022–23 First Quarter Finances planning assumption for real GDP growth in 2022 is 3.5 per cent, 0.1 percentage points lower than the private‑sector average for prudent planning purposes.

Expectations for Ontario’s nominal growth have been revised higher since the 2022 Budget as GDP inflation has risen due to strong economy-wide price increases amid supply chain constraints and strong demand. Among recent private-sector forecasts, the average projected nominal GDP growth for 2022 is 9.1 per cent, above the 2022 Budget planning assumption of 6.7 per cent. The 2022–23 First Quarter Finances planning assumption for nominal GDP growth is 9.0 per cent, 0.1 percentage points lower than the private-sector average for prudent planning purposes.

Spending information for all of the Province’s programs by ministry is available on the FAO’s website at:https://tinyurl.com/3tfejdp5.

Compared to the previous year (2020-21), unaudited spending in 2021-22 was down $0.8 billion (0.4 per cent).

Health ($4.3 billion), interest on debt ($0.5 billion) and justice ($0.2 billion) all spent more in 2021-22 compared to 2020-21. Health spending was up, year-over-year, largely due to higher COVID-19-related spending and higher spending on payments to physicians.

The FAO projects the 2021-22 budget deficit will be $8.1 billion. This is an improvement of $5.4 billion compared to the Province’s 2021-22 budget deficit projection of $13.5 billion in the 2022 Ontario Budget, presented on April 28, 2022.

The FAO estimates that 2021-22 total revenue will be $1.6 billion higher and total spending will be $3.8 billion lower than forecast by the Province in the 2022 budget.

The closing date for spending transactions related to the 2021-22 fiscal year, which ended on March 31, 2022, was April 22, 2022. However, there will still be 2021-22 spending transactions that are recorded between April 22, 2022 and when the 2021-22 Public Accounts of Ontario are released. Depending on the nature of these transactions, the 2021-22 Public Accounts of Ontario may contain material changes from the information presented in this report.

Sector 2021-22 Spending Plan Q1 Changes Q2 Changes Q3 Changes Q4 Changes Total Changes Revised 2021-22 Spending Plan

Health 71,184 5 15 118 3,972 4,110 75,2

Total 178,290 -7 -9 4,122 2,708 6,814 185,104

Health: $3,972 million increase. Notable changes include:

$3,081 million increase for Health Services (Vote-Item 1416-1), including a $2,989 million increase for the Operation of Hospitals, a $222 million increase for Community Support Services and a $274 million decrease for Community Mental Health.

$489 million increase for the Long-Term Care Homes Program (Operating) (Vote-Item 4502-1).

$376 million increase for Population and Public Health (Vote-Item 1406-4), including a $332 million increase for services.

$275 million increase for Programs and Administration (Vote-Item 1416-2), including a $164 million increase for Digital Health and a $144 million increase for Cancer Treatment Services.

$260 million decrease for Ontario Health Insurance (Vote-Item 1405-1), largely for payments to physicians (-$246 million).

The Province spent $177.9 billion in 2021-22, which was $7.2 billion (3.9 per cent) less than planned.

The $7.2 billion (3.9 per cent) in net savings for 2021-22 is less than the net savings recorded in 2020-21 of $10.3 billion (5.5 per cent) but higher than the pre-COVID-19 historical annual average of $3.8 billion (2.7 per cent) between 2010-11 and 2019-20.

Sector Revised 2021-22 Spending Plan 2021-22 Unaudited Spending Unaudited Spending vs. Revised Spending Plan Unaudited Spending vs. Revised Spending Plan (%) Health 75,294 73,477 -1,817 -2.4%

Total 185,104 177,926 -7,178 -3.9%

Health sector spending: $1,817 million (2.4 per cent) below plan. Highlights include: $104 million below plan in Drug Programs (Vote-Item 1405-2), which funds a number of provincial drug programs, the largest of which is the Ontario Drug Benefit program. $159 million below plan in Ontario Health Insurance (Vote-Item 1405-1), which administers payments to physicians. $196 million below plan in the Long-Term Care Homes Program (Operating) (Vote-Item 4502-1), which funds the operation and development of long-term care homes. $322 million below plan in Health Services (Vote-Item 1416-1), which funds the operation of hospitals, home care, community services (mental health, health centres and support) and other services. $878 million below plan in Population and Public Health (Vote-Item 1406-4), which is mainly driven by $1.1 billion in below-planned spending for the COVID-19 Response program[5] and $320 million in above-planned spending for supplies. (Note: Ministry of Health staff reported to the FAO that additional 2021-22 spending will be reported in the 2021-22 Public Accounts of Ontario that may materially change the final year-end position for this vote-item.)

In 2021-22, the Province spent $177.9 billion, which was $0.8 billion (0.4 per cent) less than was spent in 2020-21.

he largest year-over-year spending decrease was in ‘other programs’ (-$4,421 million), followed by education (-$907 million) and children’s and social services (-$446 million). Conversely, health ($4,329 million), interest on debt ($496 million), justice ($171 million) and postsecondary education ($1 million) all spent more in 2021-22 compared to 2020-21.

Health 73,477 69,148 4,329 6.3%

Total 177,926 178,703 -777 -0.4%

Ministry of Long-Term Care Long-Term Care Homes - Operations 277

Table 4: 2021-22 budget deficit projections, 2022 Ontario Budget vs. FAO Projection, $ millions * Consolidated expense includes additional spending (an estimated $5.4 billion in the FAO's projection) by the broader public sector organizations controlled by the Province (hospitals, school boards and colleges), the Province's agencies and the legislative offices. Source: 2022 Ontario Budget and FAO analysis of information provided by Treasury Board Secretariat. Province FAO Difference

Revenue 173,572 175,189 1,617

Health 79,015 76,538 -2,477

Unallocated funds cannot be spent directly by the Province but must be transferred to government programs through Treasury Board Orders.

Table 6: Fourth quarter transfers from the Time-Limited COVID-19 Fund, $ millions

Ministry of Health Operation of Hospitals 834

The health sector spent $4,329 million (6.3 per cent) more in 2021-22 compared to 2020-21, largely due to higher spending for: Population and Public Health ($2,199 million); payments to physicians ($1,551 million); the operation of long-term care homes ($843 million) and capital investments ($324 million); Home Care ($276 million) Ontario Drug Programs ($230 million); Major Hospital Projects ($141 million); the Assistive Devices Program ($96 million); Community and Priority Services ($85 million); Cancer Treatment Services ($78 million); and Canadian Blood Services ($73 million); offset by lower spending on: Small Hospital Projects (-$210 million); Regional Coordination Operations Support (-$443 million); and the Operation of Hospitals (-$1,221 million).

Table 7: Fourth quarter transfers from the Contingency Fund, $ millions

Ministry of Health Operation of Hospitals 452

During the 2030s and 2040s, the FAO projects a steady deterioration in Ontario’s budget balance, reflecting faster growth in program spending and interest payments compared to revenues. Ontario is not projected to balance its budget over the long term. By 2050-51, the deficit widens to -1.6 per cent of GDP, similar to the rate recorded during the pandemic.

Over the next 30 years, demographic changes will contribute to significant fiscal challenges for Ontario. Slower labour force growth will result in more moderate economic growth, leading to slower revenue gains. The aging baby boom cohort will continue to put pressure on Ontario’s health care system. Given these trends, persistent and rising budget deficits are projected to cause a steady increase in Ontario’s debt burden over the long term,  prompting concerns about the province’s fiscal sustainability.

Overall, the FAO projects that Ontario’s finances will remain largely manageable over the long term although fiscal flexibility will be constrained. The FAO projects that all four fiscal indicators will improve in the 2020s. However, in the 2030s and beyond, growth in program spending and interest payments will outpace revenue gains, increasing pressure on the province’s finances. By 2050-51, growing deficits will raise the debt burden to near its high point during the pandemic while interest expense as a share of revenue will climb above its historical average.

Several factors exist that could undermine Ontario’s fiscal outlook over the long term.

The FAO projects that Ontario’s budget will remain in deficit over the projection period.

The budget deficit as a share of GDP is projected to remain relatively stable until 2030, after which it deteriorates to -1.6 per cent of GDP by 2050-51, similar to the pandemic period. The deterioration in budget balance reflects faster growth in program spending and interest payments[6] compared to revenue gains.

Historically, Ontario’s net debt-to-GDP ratio has grown significantly after each major economic downturn and generally remained stable at those elevated rates in subsequent years. The FAO projects that Ontario’s net debt as a share of GDP will decline modestly until the mid-2030s, after which the trend reverses as smaller primary surpluses and faster growth in interest payments[8] lead to increased borrowing. By 2050-51, the net debt-to-GDP ratio reaches 41.0 per cent, close to its peak observed in 2020-21.

Risks to Ontario’s Fiscal Outlook

In the FAO’s projection, the government is not expected to achieve a balanced budget.

The COVID-19 pandemic resulted in a temporary increase in government spending over the short term, rising from 18 per cent of nominal GDP in 2019-20 to a high of 21 per cent in 2020-21. As the temporary COVID-19 spending fades, the FAO projects that total spending as a share of GDP will decline to 17 per cent by 2023-24.[13]

Ontario faces capital expenditure pressures, including an infrastructure backlog of $16.8 billion in 2020 that is expected to reach $22.7 billion by 2029-30, and the impact of climate change which will raise the cost of maintaining Ontario’s infrastructure as climate hazards become more extreme.[11] Adapting public infrastructure to withstand climate hazards will also require significant investment. Addressing these infrastructure funding gaps would require additional capital spending and would increase the province’s borrowing and debt levels in the FAO’s current projection.[12]

The FAO projects a gradual increase in interest rates over the projection, consistent with most economic forecasters. However, if interest rates rise faster and higher than expected, this will put considerable pressure on Ontario’s finances – see Box 1 below.

In the long term, the FAO projects average annual real GDP growth of 2.0 per cent, slower than the historical average of 2.3 per cent.

Over the remainder of the projection, total spending is expected to rise steadily as a share of GDP to around 19 per cent by 2050-51. This increase is driven primarily by the ongoing rise in health care expenses, which are projected to grow faster than the economy. In contrast, spending on education and all other programs[14] will decline as a share of GDP over the projection, consistent with long-term historical trends. By the 2040s, higher debt interest payments will also contribute to the rising GDP share of total government expenditures.

The demand for public services generally increases as the population grows and ages. Public sector wages and the cost of providing public goods and services will also increase as prices rise.

Based on the FAO’s outlook for increased inflation, faster growth in the school-age population, and continued impacts from population aging, program spending is expected to grow modestly faster over the projection, averaging 4.0 per cent during the 2020-21 to 2050-51 period.

Health sector spending is projected to grow at an average annual rate of 4.9 per cent per year, in line with historical trends. While health inflation is projected to be somewhat higher than the historical experience, especially in the next two years, Ontario’s population growth is projected to ease over the projection. In addition, the impact of aging on Ontario’s health care expense is projected to be broadly in line with the historical experience

Education sector spending is projected to grow at an average annual rate of 3.3 per cent per year, somewhat faster than historical trends.

‘All other’ programs, which includes all program spending not accounted for in the health and education sectors, is projected to grow at an average annual rate of 2.9 per cent per year, somewhat slower than historical trends.

Over the long term, the FAO projects total revenues will remain stable at 17 per cent of GDP,[24] as revenues grow at an average annual rate of 3.9 per cent during the 2021-22 to 2050-51 period, weaker than historical experience and reflecting slower growth in federal transfers and other revenue.

Total taxation revenue is expected to grow at an average annual rate of 4.0 per cent, consistent with the FAO’s economic projection, which expects very strong growth over the next several years as the Ontario economy rebounds from the pandemic

The pace of tax revenue growth slows in the post-pandemic period as economic growth moderates.

If the government makes future announcements such as new tax cuts, spending initiatives or a combination of both, the FAO’s projection of fiscal indicators would deteriorate.[10]

Corporations tax revenue will slowly decline as a share of GDP, as corporations continue to use tax preferences to limit tax liabilities, resulting in slower growth in corporate tax revenues relative to business profits.

Federal transfer revenue is projected to grow at an average annual rate of 3.1 per cent[27] over the long term based on current federal-provincial agreements. The slower rate of growth compared to history reflects:

the federal government’s policy to increase the Canada Social Transfer by 3 per cent per year and limit increases in the Canada Health Transfer to the growth rate of Canadian nominal GDP beginning in 2017-18;[28] and

Personal income tax revenue as a share of GDP will increase slightly over the projection, the result of the progressive nature of the income tax system, as income growth pushes taxpayers into higher tax brackets.

The GDP price deflator – a measure of economy-wide prices – is forecast to rise at an average annual rate of 1.9 per cent, modestly above historical performance, but consistent with trends since the early 2000s. Combining the outlook for these two factors, nominal GDP growth is projected to rise at an average annual pace of 4.0 per cent, modestly slower than the historical average.

The FAO’s projection for slower economic growth is reflected across the outlook for each component of real GDP:

Real consumption (i.e., spending excluding the effects of price inflation) is projected to grow at an average rate of 2.1 per cent per year, as household spending eventually grows in-line with real income gains.

Real investment is projected to increase by 2.4 per cent per year on average, reflecting moderate growth in business investment and residential construction spending growth broadly aligned with demographic drivers.

Real imports and exports are forecast to grow more slowly over the projection than in the past, as the slowdown in the pace of global trade integration continues.

The projection for slower population growth combined with a lower overall rate of labour force participation results in weaker growth for Ontario’s labour force over the outlook.

Weaker labour force growth is a primary contributor to the forecast for slower economic growth over the outlook compared to the past.

As the economy continues to improve over the next several years, job gains are expected to remain strong and gradually moderate to average annual growth of 1.1 per cent over the outlook.

Ontario’s productivity growth has been slowing, particularly since the late 1990s, reflecting in part the relatively weak performance of the province’s export sector, which faced intense competition from low-cost jurisdictions. This contributed to a broad structural shift in the composition of the province’s economy, with high-productivity manufacturing jobs being replaced by less productive service-sector jobs.[36]

From 2031-32 to 2050-51, health sector spending is projected to grow at an average annual rate of 4.9 per cent, consistent with the historical average. While overall population growth is projected to slightly moderate during the 2030s and 2040s, the FAO assumes that increased program enrichment will offset this reduced spending pressure.

The FAO’s projection assumes productivity will rise by an average of 0.9 per cent annually, consistent with the consensus outlook of other long-term forecasters. The expectation of relatively moderate productivity growth over the outlook is a key contributor to the projection for slower economic growth

While the International Monetary Fund expects limited lasting damage from the COVID-19 pandemic for advanced economies,[39] unanticipated geopolitical developments[40] and other long-term issues could affect Ontario’s outlook.

The FAO’s current projection assumes that climate change does not materially affect Ontario’s economy in the long term.

Program Expense 16.6 16.6 16.3 16.4 16.8

Health 6.4 8.3 7.6 8.3 9.1

Education 3.6 3.0 3.0 3.0 2.9

Health sector spending is projected to grow at an average annual rate of 5.0 per cent over the near term, slightly above the historical average of 4.9 per cent, driven by the ongoing rise in the number of seniors, as well as higher inflation and population growth. Policy impacts are projected to reduce average annual health sector spending by 0.2 per cent over the near term, due in part to below-inflation compensation increases for physicians and hospital workers, slightly offset by higher projected spending in long-term care homes.[54]

The rebound in Ontario’s economic growth from the pandemic has been stronger than expected, and real GDP is projected to surpass pre-pandemic levels in 2022. However, Ontario’s economy faces several risks that could lead to a slower recovery over the next several years.

policy impacts are projected to reduce average annual spending growth by 0.9 per cent, due in part to below-inflation compensation increases for education sector workers

in addition to changes to cost-sharing agreements with municipalities for childcare transfer payments, and the Childcare Access and Relief from Expenses (CARE) tax credi

In the health sector, the Province spent $999 million (39 per cent) of the $2.5 billion revised budget for the COVID-19 Response program. There was also lower-than-expected spending on payments to physicians, provincial drug programs and hospital capital projects.

As of December 31, 2021, $3.1 billion in unallocated funds remained in the Contingency Fund and the Time-Limited COVID-19 Fund. However, in the Province's 2021-22 Third Quarter Finances, which reflects government decisions on the use of unallocated funds through to February 2, 2022, the Province reported remaining unallocated funds of $1.6 billion. This indicates that the Province transferred approximately $1.5 billion in unallocated funds to various government programs between January 1, 2022 and February 2, 2022.

Looking ahead to the fourth quarter, the FAO expects that the pace of government spending will increase due to the impact of the Omicron wave of the COVID-19 pandemic on the health sector and the introduction of new fourth quarter spending programs.[3]

$32 million decrease for Health Services (Vote-Item 1416-1), consisting of a $105 million decrease for the Operation of Hospitals (these funds were transferred to the Ministry of Government and Consumer Services’ Ontario Shared Services program for the procurement of Personal Protective Equipment (PPE) and other COVID-19-related supplies), a $61 million increase for Home Care, and a $12 million increase for Community Mental Health.

Over the first three quarters of the 2021-22 fiscal year, the Province spent $119.9 billion. Overall, this is $5.5 billion (4.4 per cent) less than planned,[8] which is a slower pace of spending than over the same time period in the last two fiscal years.[9]

Looking ahead to the fourth quarter, the FAO expects that the pace of spending will increase due to the impact of the Omicron wave of the COVID-19 pandemic on the health sector and the introduction of new fourth quarter spending programs.[10]

$272 million above plan in Long-Term Care Program (Capital) (Vote-Item 4502-2), which provides capital funding to long-term care homes.

$209 million above plan in Health Services (Vote-Item 1416-1), which funds the operation of hospitals, home care, community services (mental health, health centres and support) and other services.

$169 million above plan in Programs and Administration (Vote-Item 1416-2), which funds Ontario Health programs and administration (Cancer Treatment and Screening, Digital Health, Regional Coordination Operations Support, Organ and Tissue Donation and Transplantation Services, etc.).

$177 million below plan in Health Capital (Vote-Item 1407-1), which provides capital funding to hospitals and other health care facilities.

$314 million below plan in Drug Programs (Vote-Item 1405-2), which funds a number of provincial drug programs, the largest of which is the Ontario Drug Benefit program.

$470 million below plan in Ontario Health Insurance (Vote-Item 1405-1), which administers payments to physicians.

$670 million below plan in Population and Public Health (Vote-Item 1406-4), which is mainly driven by below-planned spending on the $2.7 billion COVID-19 Response program.[11] As of December 31, 2021, the Province had spent $999 million directly from the program’s budget and transferred $107 million to other programs,[12] resulting in remaining funds of $1.5 billion.

The health sector spent $2,195 million (4.5 per cent) more in the first three quarters of 2021-22 compared to 2020-21, largely due to higher spending for: Population and Public Health ($1,390 million); payments to physicians ($718 million); the operation of long-term care homes ($375 million) and capital investments ($441 million); Ontario Health programs and administration (Cancer Treatment and Screening, Digital Health, Regional Coordination Operations Support, Organ and Tissue Donation and Transplantation Services, etc.) ($269 million); Community and Priority Services ($114 million); and the Assistive Devices Program ($91 million); offset by lower spending on: Home Care (-$93 million); Health Capital (-$193 million); Ontario Drug Programs (-$239 million); and The Operation of Hospitals (-$866 million).

$123 million increase for the Long-Term Care Homes Program (Operating) (Vote-Item 4502-1).

This section highlights key third quarter spending plan changes by sector and vote-item. For information on all of the Province’s transfer payment programs and ministries, visit the FAO’s website at: https://tinyurl.com/y8vy3jf9. Health: $118 million increase. Notable changes include:

The increased revenue forecast is primarily due to higher than projected taxation revenue attributable to stronger than expected nominal gross domestic product (GDP) growth in 2021 and higher net tax assessments for 2020 and prior years. Nominal GDP is estimated to have increased 11.9 per cent in 2021, higher than the prudent 2021 Ontario Economic Outlook and Fiscal Review nominal GDP growth planning assumption of 9.0 per cent.

Ontario's real GDP increased 1.4 per cent in the third quarter of 2021, after a 1.2 per cent decline in the second quarter. As of the third quarter, Ontario's real GDP was 1.2 per cent below the fourth quarter of 2019.

Ontario's net debt-to-GDP ratio is projected to be 40.8 per cent in 2021–22, 8.0 percentage points lower than the 48.8 per cent forecast in the 2021 Budget and 2.6 percentage points lower than projected in the 2021 Ontario Economic Outlook and Fiscal Review.

The government recognizes that economic uncertainty and challenges, including the rising cost of living, continue.

The Province's 2021–22 deficit is projected to be $13.1 billion — $20.0 billion lower than the outlook published in the 2021 Budget and $8.4 billion lower than projected in the 2021 Ontario Economic Outlook and Fiscal Review.

Revenues in 2021–22 are projected to be $176.7 billion — $22.6 billion higher than forecast in the 2021 Budget and $8.0 billion higher than projected in the 2021 Ontario Economic Outlook and Fiscal Review. The increased revenue forecast is primarily due to higher than projected taxation revenue attributable to stronger than expected nominal GDP growth in 2021 and higher net tax assessments for 2020 and prior years.

Program expense is projected to be $175.8 billion — $2.8 billion higher than the 2021 Budget outlook. Since the 2021 Ontario Economic Outlook and Fiscal Review, the government has made $2.3 billion in additional investments, primarily in health care and supports for businesses and workers impacted by public health restrictions to blunt the spread of Omicron. After offsetting the cost of these investments against existing contingencies and accounting for ministry underspending, program expense is projected to be $0.4 billion lower relative to the outlook presented in the 2021 Ontario Economic Outlook and Fiscal Review.

With the release of the 2021 Ontario Economic Outlook and Fiscal Review, the Time-Limited COVID-19covid 19 Fund had a $2.7 billion allocation to respond to the ongoing uncertainty related to the pandemic and the future pace of economic recovery. In response to the rise of the Omicron variant and the resulting necessary public health restrictions, additional support has been provided through the Time-Limited COVID-19covid 19 Fund. After the drawdowns reported in both the 2021 Ontario Economic Outlook and Fiscal Review and the 2021–22 Third Quarter Finances, the balance of this Fund is $500 million for the remainder of the fiscal year.

With the release of the 2021–22 Third Quarter Finances, the reserve has been maintained at $1.0 billion, which can be used to address any unforeseen events that could arise before the fiscal year-end.

The International Monetary Fund projects global real GDP to rise by 5.9 per cent in 2021, followed by 4.4 per cent growth in 2022. U.S. real GDP increased by 5.7 per cent in 2021 and, according to the Blue Chip Economic Indicators survey, forecasters expect U.S. real GDP to increase by 3.9 per cent in 2022.

Corporations Tax revenue increased by $5.3 billion, mainly due to higher 2020 and prior year tax assessments;

Personal Income Tax revenue increased by $1.3 billion, mainly due to higher compensation of employees growth for 2021, reflecting growth in employment, partially offset by weaker 2020 and prior year tax assessments;

Employer Health Tax increased by $529 million, mainly due to higher compensation of employees growth for 2021, reflecting growth in employment;

$1.3 billion in additional funding to support hospitals during the COVID-19covid 19 pandemic, including expenses such as personal protective equipment, additional staff and Infection Prevention and Control measures, as well as funding to support the rollout of COVID-19covid 19 vaccines;

$164 million to help long-term care homes prevent and contain the spread of COVID-19covid 19, including increased staffing supports and purchasing additional personal protective equipment supplies;

$108 million to train up to 8,200 new personal support workers (PSWs) for high-demand jobs in Ontario's health and long-term care sectors to address the personal support workforce shortage;

The Province's cost of borrowing has, however, increased to 2.1 per cent, higher than the 1.9 per cent forecast in the 2021 Budget and the 2021 Ontario Economic Outlook and Fiscal Review.

Despite this increase, lower forecast long term borrowings for this year have allowed the interest on debt projection to remain unchanged, at $13.0 billion.

In order to maintain continued flexibility during this uncertain time, as the 2021–22 fiscal year unfolded, the Province allocated $2.2 billion to the Time-Limited COVID-19covid 19 Fund in 2021–22 as part of the 2021–22 First Quarter Finances, with an additional $500 million increase to this Fund announced in the 2021 Ontario Economic Outlook and Fiscal Review. After all projected drawdowns reported in the 2021–22 Third Quarter Finances, the remaining balance of the Time-Limited COVID-19covid 19 Fund for 2021–22 is $500 million.

ntario's real GDP increased by 1.4 per cent in the third quarter of 2021, following a decline in the second quarter.

Since the release of the 2021 Ontario Economic Outlook and Fiscal Review, the government has invested an additional $2.3 billion, primarily in the health care system and supports for businesses and workers. Highlights include: $1.3 billion in additional funding to support hospitals with personal protective equipment, additional staff and Infection Prevention and Control measures, as well as funding to support the rollout of COVID-19covid 19 vaccines;

The Ministry of Finance is estimating that Ontario real GDP increased 4.4 per cent in 2021, up slightly from the 2021 Ontario Economic Outlook and Fiscal Review real GDP growth planning assumption of 4.3 per cent. Ontario nominal GDP is estimated to have increased 11.9 per cent in 2021, higher than the prudent 2021 Ontario Economic Outlook and Fiscal Review nominal GDP growth planning assumption of 9.0 per cent.

The private-sector average forecast footnote 1 [1] for Ontario real GDP growth in 2022 is 4.2 per cent, lower than the private-sector average increase of 4.6 per cent forecast at the time of the 2021 Ontario Economic Outlook and Fiscal Review. The private-sector average forecast for Ontario nominal GDP growth in 2022 is 7.0 per cent, higher than the private-sector average forecast increase of 6.7 per cent at the time of the 2021 Ontario Economic Outlook and Fiscal Review.

Ministry Expense 2021–22: 2021 Budget 2021–22: Current Outlook 2021–22: In-Year Change

Health (Total) 64,016.7 64,093.5 76.8 COVID-19 Health Response17 5,144.1 6,656.1 1,512.0

Long-Term Care (Total)23 5,764.0 5,886.6 122.5

Between 2013 and 2018, registered nurse employment levels across all sectors remained the same, while registered practical nurse levels rose by 15.1% and nurse practitioner levels rose by 130.6%. The number of registered nursing staff of all nursing classes rose by 9.5%. footnote 21 [21]

58% of employees are personal support workers (PSW), followed by registered nurses (RNs) at 25% approximately 40% of registered nurses and registered practical nurses (RPNs), and 63% of nurse practitioners work full-time approximately 25% of personal support workers who have two or more years of experience leave the sector annually

While the demand for long-term care and resident acuity have increased year over year, staffing levels and access to training have not kept a corresponding pace. Over time, the demand placed on long-term care staff often causes greater workload. This can increase the risk of worker injury, lead to less attention and time spent per resident and contribute to a stressful working environment. Issues such as working conditions and a negative public image have also contributed to staffing shortages in the sector.

While the province's legislative and regulatory framework is designed to ensure that long-term care residents live in a safe environment and hold long-term care homes accountable, several operators and associations have reported that the framework can be a barrier for exploring potential solutions for staffing shortages and issues.

Across the sector, long-term care partners have identified the current culture of long-term care as one based heavily on compliance, which can create a punitive environment for staff. It was also heard that the current funding model for long-term care homes is too complex and requires high levels of documentation, which takes staff away from spending quality time with residents.

Action must to be taken to: urgently address the staffing crisis in long-term care make long-term care homes a better place to live and work implement staffing approaches that reflect and respond to the complexity of the sector and diverse resident needs

The Advisory Group provides recommendations within five priority areas to improve staffing across the sector: The number of staff working in long-term care needs to increase and more funding will be required to achieve that goal. Staffing investment Minimum daily average of four hours of direct care per resident Guidelines for improving staffing ratios and skill mix for PSWs, nursing staff, and allied health professionals, with variance to address specific circumstances. The culture of long-term care needs to change – at both the system and individual home level Regulatory modernization A quality improvement approach to sector oversight Renewed performance measurements A strong coherent philosophy of care Recognition of the critical role of PSWs Respectful team environment Workload and working conditions must get better, to retain staff and improve the conditions for care. Compensation Full-time and part-time employment Protection from physical, mental and emotional risk Charting and documentation Medication management Excellence in long-term care requires effective leadership and access to specialized expertise Clarifying the role and accountability of the Medical Director Expanding the use of Nurse Practitioners Ensuring access to strong Infection Prevention and Control (IPAC) expertise Accessing specialists Attract and prepare the right people for employment in long-term care, and provide opportunities for learning and growth. Attracting people with the right personal attributes through: improved public perception stronger relationships with secondary schools enhanced supports for new graduates expanding the labour pool Aligning the number of graduates with needs across the health care sector Addressing educational requirements for the long-term care sector by: increasing onsite experiences for students promoting preceptorships Supporting staff to stay current, gain new skills and develop specialized expertise, including: continuing education micro-credentialing and job laddering

A high concentration of outbreaks (defined as a single, laboratory confirmed case of COVID-19 in a resident or staff member footnote 2 [2] ) and mortality occurred within Ontario's long-term care homes. footnote 3 [3]

To address this recommendation, the Ministry of Long-Term Care launched a long-term care staffing study in early 2020, with support from an external Advisory Group. This group was instructed to directly respond to Recommendation 85, as well as to seek broader input on a wider range of long-term care staffing issues.

As of mid-July 2020, 21.5% of confirmed cases of COVID-19 in Ontario were reported to be long-term care residents and staff, and 63.7% of deaths with COVID-19 were long-term care residents and staff. footnote 4 [4]

Long-term care homes employ over 100,000 staff across the province, not including staff service providers who come into the home to provide special services such as x-ray technicians and optometrists. footnote 5 [5] As of 2018, homes reported over 56,000 full time equivalent (FTE) positions that provide direct care to residents across the sector, compared to 43,023 reported FTEs in 2009. footnote 6 [6] The number of beds increased by 2,799 in the same time, which is approximately a four percent increase in beds.

The largest proportion of employees in long-term care are: personal support workers (58%) registered nursing staff (including registered practical nurses, registered nurses, and nurse practitioners) (25%) allied health professionals and programming support (such as activity assistants, dietitians, occupational and physical therapists, and social workers) (12%)

Each year, long-term care homes across Ontario submit reports about staffing to the ministry. This information is used to generate the Long-Term Care Home Staffing Report (Staffing Report). footnote 7 [7] According to the latest available report (2018), 41% of PSWs work full-time, 48% work part-time, and 10.7% are casual. footnote 8 [8] , footnote 9 [9] Approximately half of these employees would prefer to work more hours, and 7% would prefer to work less; while 43% are satisfied with the number of hours they work. footnote 10 [10]

Personal support workers (PSWs) in the health care sector As of 2018, there were 100,000 PSWs employed in Ontario in all healthcare sectors. footnote 11 [11] 50,000 of these employees work in long-term care, where they share the equivalent of 32,700 FTEs. 90% of the personal support worker workforce in the health care sector is female. 50% of the personal support worker workforce in the health care sector are between 35 and 54 years old 25% of the remaining personal support workers are 55 years or older. 41% of the personal support worker workforce in the health care sector are visible minorities

MLTC understands that the number of training positions has not declined, but instead there has been a reduced interest of students to enter the PSW training programs. footnote 12 [12] 2015/2016 - Over 8,000 students enrolled in personal support worker training programs (for example, public programs, private programs and boards of education). 2018/2019 - Approximately 6,500 students enrolled in personal support worker training programs. PSW Retention Within The Health Care Sector Approximately 25% of personal support workers who have two or more years of experience leave the long-term care sector annually According to Health Force Ontario, 50% of personal support workers are retained in the health care sector for fewer than 5 years, and 43% left the sector due to burnout of working short staffed. footnote 13 [13] Approximately 40% of personal support workers have left the health care sector after graduating or within a year of training The average overall job tenure of a personal support worker (in all sectors) has dropped 10 months to 85-90 months between 2015 and 2017. Turnover is highest for part-time and casual positions predominantly held by entry-level personal support workers.

Registered nursing staff are the second largest population of long-term care employees: 63% of nurse practitioners (NPs), 40% of registered nurses (RNs), and 39% of registered practical nurses (RPNs) work full time 35% of nurse practitioners, 41% of registered nurses, and 45% of registered practical nurses work part time 2% of nurse practitioners, 19% of registered nurses, and 16% of registered practical nurses work 'casual' footnote 18 [18]

Approximately 30% of registered nurses and registered practical nurses working in long-term care hold two or more jobs. footnote 19 [19]

Registered nursing staff in the long-term care sector In 2018, 23,701 registered practical nurses, registered nurses and nurse practitioners were employed in the long-term care sector. footnote 20 [20] 62.9% registered practical nurses 36.5% registered nurses 0.6% nurse practioners

Long-term care homes employ over 100,000 people across Ontario They serve an increasingly medically complex population of approximately 78,000 residents.

New graduates of PSW programs find the biggest gap is in preparedness for the speed at which tasks need to be completed. Task shifting, 'working short', and other pressures can make it difficult to utilize the concepts and techniques learned in the classroom. footnote 68

Allied health professionals and programming support In 2018, 9,700 allied health professionals and programming support staff worked in the long-term care sector. footnote 25 [25] This group of staff includes, but is not limited to: Dieticians Health Care Aides Physiotherapists Administrative Staff Social Workers

The mix of these groups can differ slightly depending on the type of home. For the top 10 job classifications, homes have largely the same staffing mix. However, slight variations exist; for example, homes of under 64 beds tend to have fewer PSWs and more RNs and healthcare aides per resident, than larger homes.

he provincial government provides 60% to 70% of home funding, and the remainder comes from sources such as resident co-payments, fundraising, and municipal governments. footnote 27 [27] How homes can spend this funding is prescribed by eligibility criteria, yet it can still vary to a degree.

For instance, total spending on compensation accounts for approximately 71.3% of total expenses in for-profit homes, 73.3% in not-for profit homes, and 81% in homes operated by municipalities. footnote 28 [28] This variation may be due to different funding sources such as municipal government funding and fundraising, and how these funds are allocated within each home.

As of 2018, homes report an average of 3.73 direct hours of care per resident, per day based on paid hours. This breaks down to an average of two hours and 18 minutes from PSWs, one hour and 2 minutes from RNs or RPNs, and 24 minutes from allied health professionals and programming support. The chart below depicts how paid care hours for caregiving staff per resident has increased by 15% between 2009 and 2018. footnote 30 [30]

Worked hours are the hours that are spent by staff carrying out the mandate of theservice, for example, staff are present and available for work. Worked hours include regular worked hours, worked statutory holidays, relief/ replacement hours for vacation and sick days, overtime and callback hours paid and banked and attendance at committee meetings and informal education. Paid hours includes all worked hours, with the addition of vacations, statutory holidays, and benefits.

It is difficult to accurately compare Ontario with other Canadian jurisdictions given differences in measurement. In terms of paid care hours per resident, Alberta reports providing 3.6 hours of nursing and personal support with an additional 0.4 hours from allied healthcare providers. footnote 31 [31] British Columbia provides 3.6 worked hours, with additional direct care from allied health care providers. footnote 32 [32]

Paid direct hours of care per resident per day in Ontario footnote 33 [33] Year Personal care hours Nursing hours Allied health and program support hours 2009 2.1 0.85 0.26 2010 2.11 0.87 0.29 2011 1.9 1.1 0.3 2012 2.16 0.95 0.31 2013 2.16 0.96 0.3 2014 2.19 0.95 0.36 2015 2.21 0.96 0.36 2016 2.22 0.97 0.37 2017 2.24 0.98 0.37 2018 2.3 1.03 0.4

9.6% the number of registered nursing staff in the long-term care sector in has increased by 9.6% since 2013. However, the proportion of registered nurses in the long-term care sector has decreased over the same time period, while the proportion of registered practical nurses and personal support workers has increased.

Eighty one percent of residents have some type of cognitive impairment, and often residents have advanced and ongoing medical conditions, and rely on multiple drug therapies to manage them. footnote 43 [43] The demand for such services is high. As Ontario's elderly population continues to grow, the need for long-term care services, and the needs of residents within long-term care, will continue to rise.

The current long-term care waitlist is over 38,000 individuals. In general, priority on the waitlist is provided to those with the highest care needs. footnote 44 [44] The average wait time is currently 152 days, and in that time, resident needs may continue to increase. As such, long-term care becomes the home of increasingly ill people, often in the end stage of their life, with higher acuity and care needs than other care settings.

ase Mix Index: (CMI) is a measure of average resource need to address resident needs in the province, and/or home. From 2004-2009 the provincial CMI score increased by 12.2%, and by another 7.6% from 2009 to 2018.

he method for assigning priority level: (MAPLe) is a score used by care coordinators to classify long-term care applicants as potential low, moderate, high, or very high-need residents, based on their medical status, cognition, behaviour, physical functioning before they are admitted to long-term care homes. The number of applicants with high or very high MAPLe scores was 82% in 2012, and increased to 85% in 2018, and 87% in 2019.

Concerns were expressed that funding has not kept pace with rising resident acuity. Annual investment in the acuity-adjusted NPC envelope increased at an average of 2.5% per year (from $82.43 per diem in 2009-2010 to $102.34 per diem in 2019-2020, an increase of approximately $4.53 accounting for inflation). footnote 48 [48] Similarly, funding provided in the PSS envelope (including physiotherapy) increased by an average of 4.4% per year (from $8.11 per diem in 2009-2010 to $12.06 per diem in 2019-2020. An increase of $2.44 in real terms). footnote 49 [49] In the same timeframe, total long-term care funding for staffing and all other priorities increased by 33.4%, from $3.26 billion in 2009 to 2010 to $4.35 billion in 2019 to 2020. footnote 50 [50] Accounting for inflation, this is an increase of $481 million, or 11%.

As the demand for long-term care has increased, healthcare staffing levels have not kept pace. The Canadian Institute for Health Information has documented a decline in the nursing workforce, as have Ontario nursing associations. footnote 51 [51] , footnote 52 [52] , footnote 53 [53] Shortages have also been noted in PSWs. For example, approximately 6,500 PSWs graduated from an Ontario PSW training program in 2018-2019 footnote 54 [54] , and each year, approximately 40% of PSW graduates leave their job within the year following graduation. In addition, it is estimated that approximately 25% of working PSWs who have two or more years of experience leave the profession each year.

…homes can be short five to 10 PSWs in every 24-hour period. Some homes [at the meeting said they] are short 20 to 50 PSWs. The situation is worse in Northern Ontario and rural areas, but the crisis exists even in the large cities of Southern Ontario. In one rural town near London, a long-term care home reported that there were only eight days of 365 in which they were fully staffed. footnote 55 [55]

As a result of these shortages, staff often do not have enough time to provide high-quality and holistic care to residents. For example: footnote 56 [56] Operators reported missed baths, missed personal care, and a lack of toileting, among other basic care functions. This was attributed to a lack of sufficient direct care per resident per day. It was reported that PSWs are often rushed and therefore cut corners to optimize the time they have available. As a result, residents may experience increased falls, levels of depression, infections, errors, complaints, anxiety, and conflict. A labour union reported that two-thirds of PSWs and nursing staff that were polled reported that they had to tell a resident they did not have time to take them to the washroom, and the resident would then have to wait.

The healthcare sector ranks second highest for injuries resulting in time lost in Ontario, and long-term care workers are among the most at risk for physical injury within the sector. footnote 57 [57] , footnote 58 [58] As of 2015, the Workplace Safety and Insurance Board, reported 3,822 injuries among the long-term care workforce which did not result in the worker needing time off, and 1,747 which did require time off. These injuries represent 27% of total injuries resulting in time lost in the health care sector. The most common reasons for injuries requiring leave were musculoskeletal disorders (38%), exposure to contaminants or chemicals (31%), slips, trips and falls (11%), and workplace violence (9%). footnote 59 [59] , footnote 60 [60]

Another issue for staff is the lack of full-time positions for those who want them. Staff often need to work multiple part-time jobs in order to achieve a living wage.

Some organizations report a disparity between the PSWs' educational experience and reality of the long-term care work environment. While educators tend to teach to the ideal environment, the pace and nature of work in long-term care can be more challenging than what students are prepared for in training.

On average, residents in long-term care homes are 84 years old.

The current demand for key positions, such as PSWs and RNs, outpaces the supply.

This comes at a time when the population of Ontario is aging. The growth in population over age 65 has outpaced that of labour-force aged Ontarians. This has resulted in a lack of balance in the care sector, felt particularly in long-term care. The OECD estimates that by 2040, Canada will require an 80% increase in all healthcare staff (across sectors) in order to maintain the current ratio of healthcare staff to individuals 65 and over.

As long-term care is already experiencing shortages that put resident care at risk, considerable improvements to workforce attraction and retention are needed to address this gap, in addition to increases in the overall pool of qualified candidates from the education sector.