RNAO s Response to Bill 41: Patients First Act, Submission to the Standing Committee on Legislative Assembly

Transcription

1 RNAO s Response to Bill 41: Patients First Act, 2016 Submission to the Standing Committee on Legislative Assembly November 23, 2016

2 Table of Contents Summary of Recommendations... 2 About Bill RNAO Offering Solutions... 4 The Issues... 6 Analysis of Bill Definition of Health Service Provider... 6 Health Equity... 7 Health Promotion... 8 Role of LHINs in Providing and Managing Service... 8 Health System Oversight... 9 Patient and Family Councils... 9 Development of Sub-Regions Health Professional Advisory Councils Transfer of CCACs Ontario Association of Community Care Access Centres (OACCAC) Health Quality Ontario Support Services Conclusion Appendix A RNAO s Model for Health System Effectiveness Appendix B RNAO s Enhancing Community Care for Ontarians Model References R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

3 Summary of Recommendations Recommendation #1: Advance an integrated health system that is anchored in primary care. Amend section 1(3) to include all of primary care, public health units, home health-care and support service providers as health service providers (HSP). Recommendation #2: Replace "health disparities" in section 4(2) with health inequities and adopt Health Quality Ontario's definitions of "health equity" and "health inequity as outlined in its Income and Health Report. Recommendation #3: Add the following LHIN object: Advance health promotion and disease prevention through leadership in planning, funding and monitoring health promotion services that address the broad determinants of health and support community development. Recommendation #4: Remove all provisions that would position LHINs as delivering and/or managing health service delivery. Instead, empower HSPs and focus the scope of LHINs on whole system planning, integration, funding allocation, monitoring and accountability functions. Recommendation #5: Amend section 19(2) by removing the exemption of public hospitals from receiving LHIN directives. Recommendation #6: Establish patient and family advisory committees within LHINs and amend the bill to require that they reflect the diversity of the community being served. Furthermore, amend section 41 to require the ministry to establish a patient and family advisory council. Recommendation #7: Amend section 12 by explicitly clarifying that the objects of the subregions are planning, funding and integrating services; not imposing barriers, unnecessary new bureaucracy and/or new governance layers. Recommendation #8: Mandate tri-partite leadership models incorporating medicine, nursing and one other regulated health profession within each LHIN. Recommendation #9: Fully dissolve CCACs and produce true health system transformation by preventing the automatic transfer of all CCAC functions, processes and resources to the LHINs. Recommendation #10: Locate the nearly 4,100 care co-ordinators (currently in CCACs) within primary care as the sector is eager and ready. Recommendation #11: Amend section 30 to remove the requirement that OACCAC employees be automatically transferred to a new shared services corporation. Recommendation #12: Amend section 37 to require HQO to seek the advice of the public and health providers when formulating advice on the funding of health services and medical devices. 2 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

4 Recommendation #13: Remove Section 40(1) and provide adequate public funding for community support services. 3 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

5 The Registered Nurses Association of Ontario (RNAO) is the professional association representing registered nurses (RN), nurse practitioners (NP) and nursing students in all settings and roles across Ontario. RNAO extends its gratitude to the standing committee for the opportunity to review Bill 41: Patients First Act, 2016 and offer recommendations to enhance it. About Bill 41 Bill 41 was introduced by the Minister of Health and Long-Term Care on October 20 to amend 20 different statutes, including the Local Health System Integration Act, 2006 (LHSIA) and the Home Care and Community Services Act, A similar bill (210) was introduced in June, however, it did not advance beyond first reading because the legislature was prorogued. Minister Hoskins indicates that Bill 41: If passed would help us to build a [health] system that best meets the needs of Ontarians, a system that closes the gaps that exist and one that would help bring health care services to the people who truly need them most. A system that best meets the needs of patients in an equitable way is one that is truly population-focused and deeply integrated at the local level. To do that, we need strong local health system planning and strong management. 1 Bill 41 arose out of a discussion paper issued by Minister Hoskins in December and RNAO was credited for informing its development. 3 RNAO Offering Solutions Nursing is the largest regulated health workforce in Canada and is consistently regarded as the most trusted profession among members of the public. 4 There are nearly 98,500 RNs and NPs working in Ontario. 5 RNs and NPs are present in all reaches of the province and health system. They are often described as the eyes and ears of the system and are intimately familiar with what is working and where gaps exist. RNAO is proud to be a trusted health system partner that is solutions-focused and has produced a model to achieve health system effectiveness (Appendix A). The model has informed a number of policy outputs focused on transforming Ontario s health system, including (but not limited to) the following: Primary Solutions for Primary Care: 6 In 2012, RNAO led a provincial task force representative of leading system stakeholders. The purpose was to identify ways to fully utilize the competencies, knowledge and skills of primary care nurses to facilitate timely access to quality primary care. The task force was bold and visionary in recommending: Identify*ing+ areas of structural duplication and work*ing+ toward better system integration by improving linkages across all sectors and moving care coordination to primary care. Enhancing Community Care for Ontarians (ECCO): 7 In 2012, RNAO released the groundbreaking ECCO model to build a robust foundation for community care and 4 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

6 improve integration between all health sectors (Appendix B). A second version of ECCO was released in 2014 to enrich detail accompanying the policy proposal. RNAO was the first organization to recommend a single health system planner/funder the Local Health Integration Networks (LHIN); while anchoring the health system in primary care and eliminating Community Care Access Centres (CCAC) as structural entities. Review of the Local Health System Integration Act: 8 In 2014, RNAO presented to the Standing Committee on Social Policy when it reviewed the LHSIA. RNAO used the ECCO model to deliver a legislative proposal that strengthens health service delivery in Ontario. Specifically, RNAO called for a greater emphasis on health equity and the engagement of marginalized groups; amending the definition of health service providers (HSP) to include all health organizations/providers; and transitioning the planning/funding functions of CCACs to LHINs thus making the LHINs responsible for whole system planning, integration, funding allocation, monitoring and accountability functions at the local level. Response to Patients First Discussion Paper: 9 In early 2016, RNAO responded to Minister Hoskins discussion paper on strengthening patient-centred health care in Ontario. RNAO continued to urge the minister to enable LHINs to plan, integrate, fund, monitor and be ultimately accountable for local health system performance, while strongly cautioning against LHINs providing service delivery and/or management. RNAO re-iterated its call for the elimination of CCACs as structural entities and reaffirmed its insistence to relocate the nearly 4,100 care co-ordinators currently in CCACs to primary care. Mind the Safety Gap in Health System Transformation: 10 In May 2016, RNAO released the results of an investigation into the relationship between Minister s Hoskins patients first agenda and nursing human resource trends. The conclusion is that trends in nursing skill mix and organizational models of nursing care delivery run counter to the government s goals for the health system. This conclusion may thwart efforts to positively transform the system. RNAO made eight recommendations: o o o o o o The Ministry of Health and Long-Term Care (MOHLTC) develop a provincial evidence-based interprofessional HHR plan to align population health needs and the full and expanded scopes of practice of all regulated health professions with system priorities; The MOHLTC and LHINs issue a moratorium on nursing skill mix changes until a comprehensive interprofessional HHR plan is completed; LHINs mandate the use of organizational models of nursing care delivery that advance care continuity and avoid fragmented care; The MOHLTC legislate an all-rn nursing workforce in acute care effective within two years for tertiary, quaternary and cancer centres (Group A and D) and within five years for large community hospitals (Group B); LHINs require that all first home health-care visits be completed by an RN; The MOHLTC, LHINs and employers eliminate all barriers, and enable NPs to practise to full scope, including: prescribing controlled substances; acting as most responsible provider (MRP) in all sectors; implementing their legislated authority to admit, treat, transfer and discharge hospital in-patients; and utilizing fully the NP-anaesthesia role inclusive of intra-operative care; 5 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

7 o o The MOHLTC legislate minimum staffing standards in LTC homes: one attending NP per 120 residents, 20 per cent RNs, 25 per cent RPNs and 55 per cent personal support workers; and LHINs locate the nearly 4,100 care co-ordinators (currently in CCACs) within primary care to provide health system care co-ordination and navigation, which are core functions of interprofessional primary care. The Issues RNAO believes that people value Ontario s publicly-funded and not-for-profit health system. That being said, there are opportunities to improve it by tackling: Rising health expenditures and insufficient federal health transfers; 11,12 Shifting demographics and rising care complexity; 13 Delays and inequitable access to timely health services; 14,15,16 Lack of emphasis on upstream preventative measures; 17 Ineffective care transitions and lack of co-ordination; 18 Variation in the quality and safety of care. 19 These challenges are not insurmountable. By incorporating the vital enhancements outlined in this submission, Bill 41 has the potential to address these gaps. However, RNAO s biggest concern is that left as-is, Bill 41 will perpetuate current system limitations, albeit under a different façade. Instead, Bill 41 could represent a unique moment in history to transition and transform the health system. RNAO is alarmed that while the ECCO model is credited as having informed Bill 41, there are a number of shortcomings in the bill that do not align with the ECCO model. As a staple of integration process, is critical that both health structures and service delivery models be adequately addressed in the government s patients first transformation agenda. Analysis of Bill 41 Definition of Health Service Provider Section 1(3) of Bill 41 seeks to expand the definition of a HSP under LHISA. However, it is missing: most primary care organizations, public health units and home health-care providers delivering purchased community services. Effective health system integration will not occur unless there is a single body -- LHINs -- that is capable of making planning and funding decisions that consider the health system as a whole. Otherwise, there is a significant risk of perpetuating existing system limitations, including siloed decision-making that will translate into fragmentation for Ontarians. RNAO is being joined by a growing number of system stakeholders in asserting that primary care must be the foundation anchoring Ontario s health system. 20 While it is encouraging that Bill 41 classifies interprofessional primary care organizations as HSPs, these organizations still provide 6 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

8 health services to only a portion of the public (~25 per cent). Therefore, RNAO asserts that LHINs should be empowered to oversee the planning, contract management, funding and performance of all primary care entities. Otherwise, the way LHINs approach planning for primary care will be inconsistent and will not lead to a strong primary care foundation which is foundational to high performing health systems. 21,22,23 The bill does seek to strengthen the role of public health units in supporting planning, funding and service delivery. However, RNAO is concerned that the provisions in the bill are insufficient to adequately advance a population-health planning approach in Ontario. For example, sections 9 and 39(1) require the leadership of LHINs and public health units to engage on an ongoing basis. This is a vague expectation with no teeth, no clear parameters and no expected outcomes. For RNAO, public health units must assume a leading role in advancing health equity. They are experts in upstream health promotion and disease prevention, as well as analyzing population health needs and delivering community engagement. Positioning public health units within the LHIN mandate, acknowledging implementation considerations, 24 will better align public health with the rest of the system, and can stimulate a broader reach of health promotion principles in other sectors. RNAO believes that this can only happen if public health units are designated as HSPs. One of the distinctions between Bill 41 and its predecessor Bill 210 is that it includes a provision that explicitly excludes home health-care providers from the definition of a HSP when delivering a community service purchased by the LHIN. It is unclear how LHINs will be capable of advancing the minister s desire to build community care capacity, if these service providers are excluded from being HSPs? Instead, the current approach will be perpetuated whereby services are purchased from a large roster of providers, leading to an inefficient use of procurement resources and instability in the sector. Instead, RNAO urges LHINs to serve as funders of accredited home health-care and support service organizations that deliver a continuum of services and reform the funding relationship from a per-visit basis to predictable funding baskets that follow evidence-based pathways and leverage provider autonomy. This will assist in stabilizing the sector and make it more person-centred by incorporating a range of interventions, including health promotion. Recommendation #1: Advance an integrated health system that is anchored in primary care. Amend section 1(3) to include all of primary care, public health units, home health-care and support service providers as HSPs. Health Equity Given the international, 25 national, 26 and provincial 27 evidence of the importance of improving health equity and decreasing health inequities, RNAO welcomes section 4(2) in the bill. As the term "health disparities" is used more commonly in the United States and has been criticized for being less precise, 28 "health inequities" is the preferred term used by Canada's National 7 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

9 Collaborating Centre for Determinants of Health (NCCDH). 29 Robust definitions for "health equity" and "health inequity" consistent with the NCCDH 30 and usage in other Canadian jurisdictions 31 should be included such as those used by Health Quality Ontario: "Health equity is the ideal state in which all people are able to reach their full health potential and receive high-quality care that is fair and appropriate from each person's perspective, no matter where they live, who they are or what they have." 32 "Health inequity is an inequality that is an unfair, avoidable, systematic disadvantage." 33 Recommendation #2: Replace "health disparities" in section 4(2) with health inequities and adopt Health Quality Ontario's definitions of "health equity" and "health inequity as outlined in its Income and Health Report. Health Promotion Achieving the best possible health outcomes requires not only a robust health-care system to patch people up when illness strikes, but also demands robust attention to preventing illness in the first place. Some system stakeholders have identified limitations with the framing of the bill as patients first because it focuses on illness-based treatments. 34 The old adage an ounce of prevention is worth a pound of cure holds true. It is necessary for LHINs to be strong champions of health promotion and disease prevention to improve population health and ensure the sustainability of the health-care system. Bill 41 could benefit from this explicit recognition. Recommendation #3: Add the following LHIN object: Advance health promotion and disease prevention through leadership in planning, funding and monitoring health promotion services that address the broad determinants of health and support community development. 35 Role of LHINs in Providing and Managing Service A number of provisions within Bill 41, including Section 4(3) and Part VII.1, position the LHIN as a provider/manager of health services. RNAO profoundly disagrees with such a role. As captured in RNAO's ECCO report, the most effective role of the LHIN is to plan, integrate, fund, monitor and be ultimately accountable for local health system performance. It would be ineffective for LHINs to engage in direct service provision. It is challenging to row and steer at the same time. RNAO urges legislators not to perpetuate the existing limitations of CCACs by having LHINs act as a case management brokerage that allocates hours of service to Ontarians based on a command and control approach per Section 28.5(4) of Bill 41. Rather, service provision and the management of service, including service allocation at the patient level, should be the focus of health providers that have the best understanding of patient need. Recommendation #4: Remove all provisions that would position LHINs as delivering and/or managing health service delivery. Instead, empower HSPs and focus the scope of LHINs on whole system planning, integration, funding allocation, monitoring and accountability functions. 8 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

10 Health System Oversight Bill 41 enables the Minister of Health and Long-Term Care to issue operational and policy directives to LHINs; appoint an investigator to assess the management and administration of a LHIN and recommend that cabinet appointment a LHIN supervisor, all when in the public interest. It would also authorize LHINs to do the same for health service providers. RNAO supports this authority, in principle, when it is within the public interest. It is important to consider that while the minister of health and cabinet are democratically elected public officials, LHIN CEOs are not. Therefore, a clear threshold with parameters is needed to specify when LHIN CEOs can exercise this authority; along with a transparent, clear and consistent process that must be followed. The Minister of Health and Long-Term Care must retain ultimate authority and accountability for the operation of Ontario s health system. RNAO is concerned that Bill 41 excludes public hospitals from being subject to LHIN directives. This is a departure from Bill 210 and RNAO is unclear why the change was made and how it aligns with the public interest? Instead, only the minister can issue a directive to a public hospital board per section 46(2) of the bill. Recently, RNAO has seen firsthand very concerning health human resource decisions being made in public hospitals that put patients at risk. In circumstances where the public interest is adversely impacted, it is essential that LHINs in addition to the health minister -- have timely authority to issue directives to hospitals. Section 19(4) of Bill 41 also specifies that LHIN directives cannot compel a HSP that is a religious organization to provide a service that is contrary to the religion related to the organization. While RNAO supports religious freedom as part of the Canadian Charter of Rights and Freedoms, it is still essential that these organizations effectively refer patients seeking impacted services to an alternate organization and that LHINs plan to ensure there is equitable access to all services for patients. Recommendation #5: Amend section 19(2) by removing the exemption of public hospitals from receiving LHIN directives. Patient and Family Councils RNAO is encouraged to see Bill 41 requires LHINs to establish patient and family advisory committees and enables the minister to establish a patient and family advisory council. RNAO first called for patient and family councils in 2012 when it released ECCO. Recently, RNAO launched its patient and public engagement strategy to reflect the voice of the public as part of being a transparent, robust and collaborative organization. 36 Bill 41 could be enhanced by mandating that the committees/council reflect the diversity of the communities being served. The bill could further be enhanced to compel the ministry to operate a patient-family council, as opposed to leaving it as an option. This should not be problematic given that on October 26 Minister Hoskins announced his intent to create such a council R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

11 Recommendation #6: Establish patient and family advisory committees within LHINs and amend the bill to require that they reflect the diversity of the community being served. Furthermore, amend section 41 to require the ministry to establish a patient and family advisory council. Development of Sub-Regions Section 12 of Bill 41 creates sub-regions within each LHIN for the purpose of planning, funding and integrating services within these areas. RNAO has been in support of the development of sub-regions so long as they facilitate horizontal primary care integration and improve services for patients and not create barriers, unnecessary new bureaucracy, or new governance layers. It is unclear what approach will be used to implement the sub-regions. However, the bill could benefit from clarity in this regard. Recommendation #7: Amend section 12 by explicitly clarifying that the objects of the subregions are planning, funding and integrating services; not imposing barriers, unnecessary new bureaucracy and/or new governance layers. Health Professional Advisory Councils Section 14(2) of the Bill makes establishing LHIN health professional advisory committees voluntary, which is a departure from their current requirement. For many years, RNAO has been advocating for a tri-partite leadership model within LHINs that includes representation from medicine, nursing and one other regulated health profession. 38 This model champions interprofessional service delivery through leadership and ensures the perspectives of multiple health professionals is incorporated into the planning and funding process. Moreover, to provide consistency, RNAO calls for this leadership model to be mandated within each LHIN. Recommendation #8: Mandate tri-partite leadership models incorporating medicine, nursing and one other regulated health profession within each LHIN. Transfer of CCACs To strengthen the effectiveness of health service delivery and Ontario s health system as a whole, both structural and service delivery changes are needed. RNAO was the first organization to call for CCACs to be dissolved, beginning in 2012 with the release of its ECCO report. Maintaining both CCACs and LHINs results in unnecessary structural duplication. It also results in fragmentation - by design - of service delivery. It severs the ability of the LHINs to deliver whole system planning and allocate funding based on demographic and health system changes. RNAO, is also concerned, as was Ontario s Auditor General, with the administrative cost of the CCACs. 39,40,41 Furthermore, RNAO has heard a significant volume of concern from home health-care agencies, nurses, and the public regarding CCACs command and control model of brokerage. The current duality of these two agencies LHIN and CCACs, while both important in their functions, does not enable the delivery of person-centred care. The impetus for change is clear. 10 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

12 While RNAO welcomes Bill 41 s intent to dissolve CCACs, the language used in the bill is limiting. First, RNAO is concerned that use of the word may in Section 26 is insufficient and discretionary regarding the minister issuing an order to dissolve CCACs. Rather, RNAO insists that the word shall be used. Second, RNAO is concerned the bill simply seeks to transfer the CCACs, including all of their limitations to the LHINs; facilitating a merger. Indeed part V.1 of the Act is named Transfer of Community Care Access Corporations to Local Health Integration Networks. There is a significant risk that the status quo will continue, albeit under the LHINs and we have identified a number of missed opportunities that must be rectified through amendments to the bill and accompanying policy changes; some of which have already been addressed in this submission: A. Ensuring that LHINs refrain from service delivery/management. Instead, focus on policy that will re-locate the nearly 4,100 care co-ordinators currently in CCACs into primary care. 42 We know that nurse practitioner-led clinics (NPLC), community health centres (CHC) and aboriginal health access centres (AHAC) are eager and ready to locate them on their premises. 43 This is likely the same case for many family health teams and other patient enrollment models. Respecting collective agreements, this can be done through a secondment from the LHIN serving as the employer. B. Enable primary care to trigger home health-care services and co-ordinate care by utilizing the nearly 4,100 care co-ordinators and existing RNs in the sector. C. Amend Bill 41 to remove the elements of Section 26 which would result in the automatic transition of all CCAC employees to the LHIN. RNAO insists that only care providers in CCAC should be transitioned (e.g. care co-ordinators, mental health nurses in schools, nurse practitioners, rapid response nurses, etc) and be located in provider organizations. LHINs should first assess their existing management/administrative capacity to meet an expanded mandate and then initiate appropriate recruitment processes. D. LHINs should include home health-care and support service providers as HSPs. Accountability agreements can be developed through a non-competitive process that favor results-based quality and safety; accreditation status and the scope of services being offered. The goal should be to ensure quality, safe, continuous and consistent services for Ontarians. Recommendation #9: Fully dissolve CCACs and produce true health system transformation by preventing the automatic transfer of all CCAC functions, processes and resources to the LHINs. Recommendation #10: Locate the nearly 4,100 care co-ordinators (currently in CCACs) within primary care, as the sector is eager and ready 11 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

13 Ontario Association of Community Care Access Centres (OACCAC) RNAO is concerned with Section 30 of the bill that essentially transfers the functions and employees of the Ontario Association of Community Care Access Centres (OACCAC) to another corporation. While there may be a need to establish a shared services corporation for LHINs, the focus should be on shared services to support LHINs in meeting their planning, funding and contract management obligations. Moreover, the LHINs and ministry must first assess what need exists and plan an appropriate scope of what this entity should entail. Although RNAO has great respect for the employees of the OACCAC, it would be irresponsible to automatically transfer them to a new organization that should have a different function from the OACCAC. Recommendation #11: Amend section 30 to remove the requirement that OACCAC employees be automatically transferred to a new shared services corporation. Health Quality Ontario Health Quality Ontario (HQO) plays an important role within the health system, including promoting evidence-based decision-making at the policy and practice levels and monitoring the performance of Ontario s health system. Given that the organization provides the minister with important advice on the funding of health services and medical devices, it is imperative that the perspectives of the public and health providers are captured. Currently, the Excellent Care for All Act requires engagement of the public in formulating this advice. This is fantastic, however, it is also important to consider the perspectives of health providers who are actively leading the delivery of health services. Recommendation #12: Amend section 37 to require HQO to seek the advice of the public and health providers when formulating advice on the funding of health services and medical devices. Support Services Section 40(1) of Bill 41 specifies that approved home care providers are able to charge clients a fee for the provision of home making or community support services. The provision of support services is a core element of promoting health. Often, the availability of support services means the difference between being able to remain at home and being transferred to a costly institutional setting. The government indicates that it wants to keep people well in their communities for as long as possible. Therefore, there should be sufficient funding provided for community support services (including basic home making) so that people are not required to pay out of pocket. Moreover, the provision in the bill is vague and offers no clarification on what is an appropriate charge and it is important to consider the populations that require these services to function. Recommendation #13: Remove Section 40(1) and provide adequate public funding for community support services. 12 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

14 Conclusion RNAO is pleased to contribute its expertise to the review of Bill 41 Patients First Act, The bill, with the pressing amendments specified in this submission, would positively transform Ontarians health system. RNAO is gravely concerned that left as-is, the bill would do little to put patients first. RNs, NPs and nursing students -- indeed all nurses -- are calling for authentic transformation. We look forward to an ongoing leadership role in health service delivery and in bringing about genuine and much needed health system improvements. Ontarians need and deserve no less. 13 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

15 Appendix A RNAO s Model for Health System Effectiveness 14 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

16 Appendix B RNAO s Enhancing Community Care for Ontarians Model 15 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

17 References 1 Legislative Assembly of Ontario (2016). Hansard for October 19, 2016: 19&detailPage=%2Fhouse-proceedings%2Ftranscripts%2Ffiles_html%2F19-OCT- 2016_L017.htm&Parl=41&Sess=2#P240_ Ministry of Health and Long-Term Care (2016). Patients First: Reporting Back on the Proposal to Stregthen Patient-Centred Health Care in Ontario. Retrieved from: 3 Ministry of Health and Long-Term Care (2015). Patients First. A Proposal to Stregthen Patient-Centred Health Care in Ontario. Discussion Paper. Retrieved from: (see page 9). 4 Gallup (2015). Honesty/Ethics in Professions. Retrieved from: 5 Registered Nurses Association of Ontario (2016). Nursing Workforce Backgrounder. Retrieved from: (with data from the College of Nurses of Ontario). 6 Registered Nurses Association of Ontario (2012). Primary Solutions for Primary Care. Retrieved from: 7 Registered Nurses Association of Ontario (2014). Enhancing Community Care for Ontarians (ECCO) V2.0. Retrieved from: 8 Registered Nurses Association of Ontario (2014). Submission to the Standing Committee on Social Policy Review of the Local Health System Integration Act and Regulations. Retrieved from: 9 Registered Nurses Association of Ontario (2016). Response to the Ministry of Health and Long-Term Care s Patients First: Proposal to Strengthen Patient-Centred Health Care in Ontario. Retrieved from: tion_-_march_2016.pdf 10 Registered Nurses` Association of Ontario (2016). Mind the Safety Gap In Health System Transformation: Reclaiming The Role of the Registered Nurse. Retrieved from: 11 Commission of the Reform of Ontario`s Public Services (2012). Chapter 5: Health. Retrieved from: 12 Registered Nurses`Association of Ontario (2015). Why Health Matters: A nurses`guide to the 2015 federal election. Retrieved from: 13 Registered Nurses`Association of Ontario (2016). Mind the Safety Gap In Health System Transformation: Reclaiming The Role of the Registered Nurse. Retrieved from: 14 Health Quality Ontario (2016). Measuring Up Retrieved from: (see primary care access) 15 Auditor General of Ontario (2015). Annual Report Chapter 3: CCACs Community Care Access Centres Home Care Program. Retrieved from: 16 Health Quality Ontario (2016). Income and Health. Opportunities to achieve health equity in Ontario. Retrieved from: 17 Ontario Chronic Disease Prevention Alliance (2016). Make Ontario the Healthiest Province. Pre-Budget Submission. Retrieved from: Budget%20Budget%20Submission_1.pdf 18 Registered Nurses Association of Ontario (2014). Enhancing Community Care for Ontarians (ECCO) V2.0. Retrieved from: 19 Canadian Institute for Health Information (2014). Your Health System: 16 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

18 20 Ontario Primary Care Council (2016). OPCC Initial Response to Minister s Patients First Proposal. Retrieved from: 21 World Health Organization (2015). Building primary care in a changing Europe. Retrieved from: 22 Schoen, C. et al (2004). Primary care and health system performance: Adults experienced in five countries. Health Affairs. (4), Baker, R. & Axler, R. (2015). Creating a high performing healthcare system for Ontario: evidence supporting strategic changes in Ontario. Retrieved from: er.pdf 24 Registered Nurses Association of Ontario (2014). Enhancing Community Care for Ontarians (ECCO) V2.0. Retrieved from: see Appendix C for a public health analysis. 25 Commission on the Social Determinants of Health (2008). Closing the gap in a generation: Health equity through action on the social determinants of health. Geneva: World Health Organization Chief Public Health Officer of Canada (2008). Report on the state of public health in Canada 2008: Addressing health inequalities. Ottawa: Public Health Agency of Canada Health Quality Ontario (2016). Income and Health: Opportunities to achieve health equity in Ontario. Toronto: Author Hofrichter, R. & Bhatia, R. (2010). Tackling Health Inequities through Public Health Practice: Theory to Action. New York: Oxford University Press. 29 National Collaborating Centre for Determinants of Health (2013). Let's Talk: Health equity. Antigonish, NS: Author National Collaborating Centre for Determinants of Health (2013). Let's Talk: Health equity. Antigonish, NS: Author Alberta Health Services (2011). Towards an Understanding of Health Equity: Annotated Glossary. Edmonton: Author, Health Quality Ontario (2016). Income and Health: Opportunities to achieve health equity in Ontario. Toronto: Author, Health Quality Ontario (2016). Income and Health: Opportunities to achieve health equity in Ontario. Toronto: Author, Association of Ontario Health Centres (2016). Submission to the Standing Committee of the Legislative Assembly regarding Bill 41 Patients First Act, Adapted from Association of Ontario Health Centres (2016). Submission to the Standing Committee of the Legislative Assembly regarding Bill 41 Patients First Act, Registered Nurses Association of Ontario (2016). Patient and Public Engagement. Retrieved from: 37 Government of Ontario (2016). Ontario Establishing Patient and Family Advisory Council. Retrieved from: 38 Registered Nurses Association of Ontario (2012). Primary Solutions for Primary Care. Retrieved from: 39 Auditor General of Ontario (2015). Community Care Access Centres Financial Operations and Service Delivery. Retrieved from: 40 Auditor General of Ontario (2015) Annual Report Chapter 3, Section 3.01 CCACs- Community Care Access Centres Home Care Program. Retrieved from: 17 R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,

19 41 Auditor General of Ontario (2010) Annual Report. Chapter 3, Section 3.04 Home Care Services. Retrieved from: pdf 42 4,100 is based on data provided by the Ministry of Health and Long-Term Care dated November 18, RNAO conducted a survey of nurse practitioner-led clinics in November R N A O s R e s p o n s e t o B i l l 4 1 : P a t i e n t s F i r s t A c t,