Taking profits out of long-term care: a conversation with Albert Banerjee

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Image: Albert Banerjee

Albert Banerjee is the research chair in community health and aging at St. Thomas University in Fredericton, New Brunswick. He has conducted extensive research on long-term care, predominantly in the Canadian context. Banerjee recently spoke with rabble about the neoliberalization of the long-term care system in Ontario and its effects on workers and residents. 

This interview has been condensed and edited for clarity. 

rabble: In your paper Centring Care, you say that while neoliberalism is associated with deregulation, that's not true for the health and social care sectors. How does that work?

Banerjee: That's an interesting contradiction. David Harvey has a lovely book on neoliberalism and he points to some of the contradictions -- I believe he thinks of it as largely a political project to enhance capital accumulation and the power of economic elites. He says, at the end of the day, it's not as much about more or less regulation, it's about moving capital to elites.

It's about moving resources and protecting wealth accumulation. And I think that kind of helps explain what we're seeing in nursing homes because it's particular kinds of regulations that have been instituted. It's not regulations, say around staffing levels, right?

I think in the U.S., people like Charlene Harrington, who is a researcher that we've worked with, is advocating for the reporting of payroll data so you can actually see not who was supposed to be at work, but who actually was at work.*

Those kinds of regulations supporting the conditions for care, we're not finding, or are actively being removed. But we are finding regulations around monitoring staff and personal support workers being put in place, right? I think in British Columbia, care aides need to be registered now. As if they are the problem.

[*In long-term care homes, staffing is often calculated to include people who are on vacation or off-duty, as opposed to people who are actually present in the facility.]

[Note: Nursing homes have often criticized for being over-regulated. Research by Pat Armstrong and collaborators, speaks about the tendency of regulations requiring detailed documentation of tasks taking time away from providing care. However, there are no such regulations around adequate staffing, which has long been avoided by ruling parties in Ontario despite strong support from unions and advocacy groups.]

So can you help explain why the business lobby in Ontario wants to deregulate long-term care? Even they seem to be concerned with the onerous regulations around charting and documentation. It's an interesting contradiction because it seems like these regulations were instituted as part of the for-profit takeover of the industry, and yet business is opposed to it. 

I think it's important to have regulations that support the conditions of care. Pat Armstrong has a chapter at the end of her book where she talks about supporting caring relationships. 

Nursing home staff need time to care, they need autonomy to make decisions, they need consistency of employment, they need experience and expertise, and we need regulations that support those things. The counting and documenting everything that we currently have tends to get in the way of providing care. 

A lot of the staff, especially at the management level is busy doing reporting; they're not on the floor. There is a disconnect because they have to do these reports. I think it's in everybody's interest to move away from that kind of regulation and [instead] put regulations that support the conditions for care. 

I can see regardless of whether you're for-profit or not-for-profit, you would support removing some of the regulations.

To understand why the regulations regime has been structured the way it is, I believe it's important to understand how it's been shaped by for-profit ownership, right? In Ontario that's currently at 58 per cent.

Absolutely. In Ontario, you have a system that that is over-regulated and has been designed to regulate as if everyone was for-profit [with more regulations being instituted in response to media scandals].

One of the most important works in the area of regulation is by Braithwaite that looks at Australian research. They take the nursing home sector as an example, precisely because they are so over-regulated. And they talk about the growth of regulation as being part of a response to the state that is retreating from providing welfare services, but [the state] still has this moral responsibility. 

Governments, rather than funding and delivering services, they have begun to monitor services. You have the development of what they call a regulatory state as opposed to a welfare state. 

I spent a couple years in Sweden. And until recently they have been both funding and delivering services. Since they have allowed for-profit actors to come in and deliver services, there are now concerns about quality and talk about the need for more regulation as a solution.

[Researcher] Charlene Harrington talks about what happens when you get a certain intensity of for-profit [ownership in the system]. Then the regulations become heavier and they become geared to prevent abuses by for-profits, which she discusses in our paper on media scandals and the growth of nursing home regulations

It seems part of the regulations regime has to do with good intentions because it seems that in Ontario the Liberals tried to cater to different segments of society, appeasing businesses, but then also trying to take care of people and over-regulating to the point of making a complete mess.

Exactly. I think that is a little bit of what has happened and it has become a mess. It might be good intentions and certainly trying to appease people who want to see private for-profit delivery.

But you can have private delivery in terms of non-profit providers. Either way, the research shows that care delivered in private for-profit facilities is inferior to the care delivered by non-profit or public facilities. Plus, where is the profit going to come from? Your biggest expense is labour. That's were the profits will need to be taken. And that hurts care. 

Ontario is facing a personal support worker (PSW) shortage crisis, which seems to be happening across the board from municipal homes to non-profits and for-profits. How should we understand this crisis? 

I would say a couple of things. First, it is challenging work. No matter where you do it, and the intensity of the work is making it more and more challenging because the people coming into the facilities are older and sicker. Policies and funding haven't adapted to that. 

We interviewed staff in British Columbia's facilities to discuss death and dying. We think of these places as facilities where people go to live, but what we were hearing is that people come in “already palliative” and often die very quickly. Staff are having to deal with the additional work and emotion of that and they're not adequately supported.

The work is emotionally and physically challenging whether you're in a non-profit or for-profit facility. But staffing tends to be better in the public or non-profit homes than the for-profit homes.

And that makes sense, right?  If we look at the way long-term care is funded, municipal and non-profits can use additional money to put money back into care [by hiring additional staff], whereas the for-profits exist to make money. So it's only logical that they will not provide the same quality of care, which is they have higher rates of hospitalizations, mortality rates and so on. 

I agree. The logic of competition doesn't apply in this field because there is a waiting list for entrance into long-term care homes. And once you're in a home it's not like buying a pair of sneakers -- if you don't like the sneaker, you never buy that brand and buy another brand. You don't move easily from one home to another.

The logic of profit and consumer choice doesn't make a lot of sense in this particular sector.

What about the idea of technological innovation and management expertise, and economies of scale for some of the larger corporations? Is there any benefit to that?

From what I've seen informally, I would say yes. But [that's regardless] of whether it's non-profit or for-profit. For instance, there are great homes we saw in Norway and Sweden. They were quite large, but they were organized in small units.

So they had small units that benefited from economies of scale. They had on-site hairdressers, they had full-time recreation staff, they were able to organize all sorts of different events because they had those economies of scale. There are large non-profits in Canada as well that can achieve economies of scale.

You can develop and share knowledge. That has more to do with fostering a culture of innovation than it does ownership status.

When you look at health authorities in British Columbia or the health networks in Ontario they also have economies of scale. But is there a culture of innovation? Is there knowledge sharing? How do you create and foster that? These are important questions.

I think there are real opportunities here. We need to move beyond the myth that for-profits are the only organizations that innovate. It's just more about whether and how you foster a culture that is good at innovating and sharing promising practices.

But then with for-profit ownership, you don't have that right? As the corporations compete against each other and are incentivized to not share information.

True. You can end up with privatized, consumer proprietary knowledge that cannot be shared. Also what's driving the 'innovation' is often cost-reduction, not necessarily better care. 

It's cost reduction within certain parameters as you can't have the care [standards] fall too low, or at least not get caught. In some of our interviews with workers who had worked in the for-profit [homes] and were now in municipal or non-profit homes, they said as soon as they could leave the for-profits, they did. 

They just felt the culture was very different. They felt there was something very tangible and problematic in the culture of the for-profit homes, which was geared around costs rather than care, as opposed to the municipal or non-profit homes. 

And that profit motive creates these precarious working conditions and part-time work and low wages and so on.

It's certainly part of it. There is a recent study in British Columbia that tracks the impact of subcontracting for instance, which is a strategy of privatization and union busting. It contributed to overwork, precarity, low wages, poor worker retention and burnout. And if you're dealing with someone with dementia, you need to know how to read their non-verbal forms of communication and they need to be familiar with you. That takes time and consistency. If you've got a lot of casuals coming in who are also stressed and burnt out, it's not a good recipe for success.

In regard to regulations, the recent report on the PSW shortage crisis said, "The culture of work was described as punitive. PSWs report that blame is a one-way street in which they are afraid of being punished for neglect or abuse, but their own working conditions are neglectful and exploitative." So essentially, the regulations regime is bad for workers.

It's a punitive regime. It's taking advantage of a vulnerable population. It's exactly what we found a decade ago in our book, They Deserve Better, which compared Canada with Scandinavia. We found similar things that haven't changed unfortunately. 

What's really sad is that this is meaningful work. We talk about an aging population as if it were a crisis. But it also means there is opportunity for really meaningful work. The workers that we interview tell us that they care about their residents, they find their work matters, they find meaning in it. And yet they are distressed because they can't provide the care that they know they're capable of and that they would be able to if they had the time and weren't rushing.

You often hear about love and family in the way staff speak about what they do when caring for residents. But they're doing it in a situation that's exploitative. But that can be changed. There is a silver lining here that these could be great jobs if properly supported.

Which means addressing the problems that relate to a predominantly for-profit industry that is underfunded. So we need to better fund long-term care -- meaning better wages and compensation for workers. Which also means addressing the neoliberal structure of government overall, right? Because we'd need to raise taxes on corporations and the wealthy to be able to pay for some of these changes

Exactly. This takes us back to neoliberalism and the politics of capital accumulation. In one of our papers, we say that most of what goes on in the home is determined outside. It's where our tax money goes and how unequal our society is. Norway for instance, does very well. And people often say that's because they're a rich society. But they're a resource-based economy like we are but what they did with their resources is very different and much more collective than what we have done. That then enables them to fund their homes better. These things are deeply connected. 

You were part of the team of experts along with Pat Armstrong and others who advised the local government on transforming Toronto's municipal nursing homes. Do you think the municipal government in Toronto understands some of the challenges we've discussing?

Yes. On the whole, I was really impressed. The people we met want to make a difference. They're inspired to innovate. What we saw in terms of conditions of care was impressive. And so part of our recommendation was not to import a single model of care but to draw from various models and local innovation -- to create something that really suits Toronto, because it is such a unique area.

These homes that you made recommendations for are all owned by the City of Toronto. So it's easier for them to implement a model of relational care [which requires much higher levels of staffing] as opposed to the [for-profit corporations] Chartwells and Extendicares, right?

Possibly. It also depends on political will and public support too. It's something that we should be proud of to have a municipality that has 10 homes and that can continue to experiment and try different things and promote a culture of innovation and flexibility. We need to encourage that by fostering a culture that is not punitive but is creative -- willing to take risks, make mistakes and learn from them. 

This can be supported by the media that is willing to report on successes and what our homes do well rather than highlight failures.

We have an obsession with costs [in relation to an aging population], which is strange because at the same time the costs of profits is not part of the conversation.

Exactly. It typically isn't spoken about. Silence around ownership is normalized. It's acceptable not to talk about profit. It's strange if you talk about it. Speaking about for-profits is considered political. I think that's something that we need to change. We're now seeing these issues being raised around climate change with people questioning neoliberalism in that context. We need to do that in the context of health care.

What I found interesting in Sweden [is the way they] talk about health care and elder care. They're an explicitly feminist country. They say that it's the role of the state to care for older people, because they recognize the gendered division of labour. Because if it's not the state, then it's typically women caring for free. 

Whereas it seems to be a given over here in Canada that unpaid caregiving will have to supplement publicly funded seniors care [driven by a for-profit model]. And that tends to impact women a lot more than men, but that's also kind of normalized and not really challenged.

Exactly. Bringing to the fore those kind of unstated assumptions is really important.

Zaid Noorsumar is rabble's labour beat reporter for 2019, and is a journalist who has previously contributed to CBC, The Canadian Press, the Toronto Star and Rankandfile.ca. To contact Zaid with story leads, email zaid[at]rabble.ca.

Image: Albert Banerjee

 
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