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Private long-term care facilities have been understaffed and underregulated for decades

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Image: Elien Dumon​/Unsplash

It's hard to believe anyone could be seriously surprised at the disaster unfolding daily in our long-term care facilities. Certainly, anyone with a relative or loved one in a nursing home -- or anyone who has ever visited such a place -- must have known, deep in their heart, that should a crisis in health care occur, it would wreak havoc and bring tragedy to those who live and work in long-term care. Yet, there was no preparedness, and no defence.

It's not as if the problems came as a big surprise, like the sudden summer storm that ruins your long-anticipated picnic. For years, if not decades, the dangers embedded in the nursing home model have been clear for all who chose to see. But most of us did not choose to see, because if we saw, then we'd be morally obligated to act, and if we don't look, the problem does not exist.

Some 30 years ago, in 1991-1992, I was appointed under the Public Inquiries Act as a one-person commission tasked with investigating conditions in Ontario's retirement homes (for seniors) and boarding homes (for ex-psychiatric patients). It was, and remains, the only systematic inquiry ever conducted into retirement homes in Ontario. In the course of my inquiry, I looked to the nursing home model to see if this might be a path worth emulating.

I recoiled in horror at what I saw in the nursing home system and explicitly recommended that this approach should not be expanded more widely. Though outside my precise mandate, I nevertheless advocated that the nursing home sector itself should be reduced over time, with more emphasis placed on community-based services that would allow people to stay in their homes for longer periods of time, with adequate support from the state. 

This remains my position today.

Things have changed in the world of nursing homes through the years. Firstly, along with population ageing has come larger numbers of frail and vulnerable seniors, living longer and in more need of support. Families are more mobile geographically than 30 years ago, and adult children have their own jobs and responsibilities, so we can no longer count on family members to serve as caregivers for elderly parents. 

Offsetting this, however, has been the development of new technologies that enable people to live outside institutions. It was not so long ago that people in need of oxygen had to reside in institutions to be hooked up to machines to help them breathe; today, by contrast, we see people walking along the street pulling a small mobile oxygen system, much like they'd pull a shopping cart. Human services such as nursing can be delivered anywhere in the community, and need not be within institutions. 

Another major change in the last 25 years, in Ontario at least, has been the dramatic increase in the proportion of long-term care beds provided by the private, for-profit sector. When I did my inquiry, about half the nursing home beds in the province were controlled by the not-for-profit sector -- some by municipalities in what were then called "homes for the aged," others by faith groups and various NGOs. The other half of the beds were the domain of the commercial, for-profit operators. With the election of the Mike Harris government in 1995, there began a massive expansion in the number of nursing home beds, almost all of it in the private for-profit sector. Licences to operate nursing home beds were awarded without cost, but immediately upon receipt became valuable assets to be bought and sold for private gain: they thus were a convenient way for any government to reward its supporters.

Subsequent governments, both Conservative and Liberal, continued the expansion in nursing home places (now called long-term care facilities); again, the overwhelming share of this expansion was in the private for-profit sector. A lot of money was being made in this process as mergers and acquisitions consolidated the industry into a smaller number of larger players. No one in government, it seems, had the creative will or the analytical interest to seek out alternatives to merely adding more buildings to warehouse frail seniors. Of course, bricks and mortar yield tangible real outcomes to which politicians can point as evidence of their grappling with a social problem -- services do not. Putting more money into community-based services has always been high on the rhetorical desirability scale, but low on the list of funding priorities. Today, the not-for-profits continue to function, and some of them are thriving, in both long-term care and in the community. But they are small potatoes alongside the large corporations that now dominate the industry.

Is this necessarily a problem? In my view it is. My PhD in economics tells me that maximization of profit is the goal of the corporation (or most other businesses), and that profit is the difference between what comes in (revenue or income) and what is paid out (costs or expenses). Maximizing profit means increasing the former and/or decreasing the latter. Incomes for long-term care centres are relatively fixed: The province pays $182 per diem for each licensed bed, with various top-ups and opportunities for user co-payment increasing this figure. With four beds to a room, this is a lucrative daily guaranteed payment for any operator.

So, the main avenue to increase profit is to reduce costs: "Continuity of care" -- knowing the patient and working with her on a daily basis -- is less important than reducing labour costs. Hence, staff are employed for limited hours so they are not eligible for benefits which only kick in at a certain hour threshold. High resident-to-staff ratios and inadequate personal protections are the hallmark of the truly marginalized workforce found in most long-term care facilities today. Keeping a stock of personal protective equipment represents dead costs, which do not enhance the bottom line. Cutting corners, such as changing sheets or underclothes less frequently, or reducing staff complement, are good for the bottom line. If there are fewer nurses or RNAs at night, who's to know?

It's important to note that not-for-profit long-term care facilities are not immune from this relentless pressure to cut costs. But it is my contention that the problem is worse today in the for-profit sector, where the stock market valuation, executive bonuses and profitability of the large corporation trump all other considerations, particularly those relating to resident care. 

So, what's the way forward? 

I think there are two paths that must be pursued simultaneously. First, we must dramatically turn our focus to the community, supporting agencies that can deliver services to people in their homes, keeping them out of long-term care beds in the first place. The number of hours of care that a person can currently receive in their home is severely limited, often as few as four or five hours a week, and even that is not available to all who need it. While this may be adequate for the individual to get help with a bath -- a weekly bath -- or some light housekeeping, it is clearly insufficient to keep someone in their own home. Substantial private money is required as a supplement to the home care, absent which the individual will be forced to move to a long-term care bed in an institution. $182 per day, now paid to the operator for each long-term care bed, could instead buy several hours of quality individualized in-home care. It won't be enough for everybody, but it will make a big difference for some.

Second, there is a need for far more oversight of all long-term care facilities. Institutions with long-term care beds will be with us for the foreseeable future. Though it is nice to envisage a kinder, better world, where no one lives in an institution -- and we should do everything possible to accelerate the arrival of this grander day -- the reality is that long-term care beds will be an integral part of the health-care world for many years to come. And the corporations that control the majority of beds in Ontario will continue to play a dominant role. But what we can do is watch them much more closely than we do at present. We can inspect to be sure that residents are at the centre of the system, that the $182 per diem is spent as intended, rather than skimmed off into somebody's pocket or some corporation's bottom line. 

There are problems with inspection and regulation to be sure: over time inspectors tend to develop ongoing relations with the service providers, while clients come and go. Minor transgressions are overlooked, and gradually, almost imperceptibly, the inspectors come to identify with those being regulated, rather than those ostensibly being protected. This process, known as "regulatory capture," potentially occurs wherever there is regulation.

Then there is the problem of sanctions or penalties. When an inspector finds a problem in a long-term care setting, the initial recourse is to informally seek its remedy. But if the problem recurs, or is severe, a more substantial response is called for. Financial penalties can simply be passed on to the residents in the form of reduced service. "Watering down the soup" was the analogy we used in my Inquiry to reflect how the long-term care operator could recoup any financial sanctions without being caught. 

In extremis -- as in some homes since the virus arrived -- it may be necessary to remove an operator entirely. But what does the state then do with the vulnerable residents? Put them out on the street when the home is closed down? In a very real sense, the operator holds the residents hostage, limiting the tools of control available to the state. The operator can be removed, a process that does occur occasionally, and a different operator brought in to run the home. Are the providers sufficiently distinguishable from one another that replacing A with B will make a real difference? Sometimes, definitely yes. At other times, not nearly so much. And watching the Ministry of Health shuffling operators around to keep a failing system afloat, one gets the clear sense that the deck chairs are being rearranged on the Titanic.

There used to be regular inspections of nursing homes in Ontario. For the reasons just indicated, the system was not perfect, but it often worked adequately. It was better than no inspection. Media stories about neglect or abuse in particular homes were not good for the home's image, and many operators who were part of the local community, cared and wanted to comply. Once again, the Harris government made major changes, cutting back inspections, and even giving advance notice before an inspector arrived. And once again, the governments that followed did not reverse this trend. The Doug Ford government within the last year, virtually eliminated inspections, leaving residents at the mercy of the large corporations that now dominate the industry.

This trend -- this neglect of our seniors in long-term care homes and their abandonment by the government that is supposed to protect them -- can be reversed. It must be reversed. And not just before the next pandemic, but as a matter of morality and day-to-day quality of life,

Ford has, by most accounts, handled himself well through the course of the pandemic, certainly by comparison to his former role model to the south. But once this is all over -- once we enter the "new normal" (whatever that may entail) -- will the Conservative government act seriously to protect our vulnerable seniors?  Will they put serious dollars into the enhancement of community-based services to enable people to stay in their homes? Or will they sacrifice seniors again by funding more for-profit long-term care facilities and/or cutting spending on seniors in the rush to get government finances under control? And will they reinstitute regular and meaningful inspections to take seriously their obligation to protect those vulnerable residents?

Those are the two tests by which we will judge whether the Ford government intends to make substantial changes so the most vulnerable Ontarians are not sacrificial lambs to the next pandemic. 

Ernie Lightman, PhD, is professor emeritus of social policy at the University of Toronto.

Image: Elien Dumon​/Unsplash

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