Seniors in long-term care facilities are dying of COVID-19 in the thousands in Canada. It is a deadly combination of their vulnerability to respiratory illness and their living situations: evidence suggests that most infections occur indoors and that mortality rates are staggeringly high in long-term care settings for seniors. On April 2, 2020, the Globe and Mail ran an opinion piece by André Picard with the headline, "If you can get your relatives out of seniors' homes, try to do so as fast as you can."
What then, Mr. Picard? Who's going to look after our people? Those who have had stable employment during the pandemic and who have been lucky enough to have been able to work from home are already dealing with the impossibility of trying to work while often caring for children, who are also home. Add aging relatives or those with ongoing complex care needs into the mix and watch how the people (mostly women) who are tasked with the care work begin to fall apart.
The idea that living with family (even with complex and chronic illness that requires a lot of care) is the best option and that all other care options are lesser is a romantic notion based on a historic and very gendered division of labour. It harkens back to an age when every household had women -- wives, mothers, sisters and daughters -- who would look after the young, the old, the elderly and the sick. This rosy vision is blind to the physical and complex medical nature of the care required for those in care homes. Not many of us have the physical power and training to lift our loved ones from a bed to toilet, nor to ensure they do not fall ill from infections and bed sores.
Long-term residential care is necessary; but it doesn't have to be a necessary evil. It cannot be provided at home, even if every person was able to find a willing provider. As a society, we broadly agree our governments should pay for long-term residential care. In Ontario, for instance, the maximum rates to be charged are set by the Ministry of Health and Long-Term Care, which also provides subsidies if needed.
But nothing requires private operators to spend all the revenue they receive from individuals, families or governments on care for residents. They can -- and many do -- pay as few staff as possible as little as possible, and keep them precarious (so they have to work multiple jobs and are more susceptible to illnesses and cross-contamination themselves). In B.C., Liberal governments allowed for more privatization and sub-contracting that failed people even before the pandemic hit. That is why the province's current NDP government moved to repair some of the damage done to care facilities in 2018.
Canada needs safe long-term care for people. The safety and well-being of people who live in these facilities depends on the safety and well-being of the staff who work there. After all, staff working conditions in any residential facility are the living conditions of residents. The conditions of work in long-term care facilities are so dismal that politicians are now falling over themselves to admit that this is driving the infection rates for COVID-19 in such settings. Even before COVID-19, the Ontario government announced a study into long-term care staffing but without including anyone representing health-care workers or their unions.
The problems with long-term homes are not new. Professor Pat Armstrong has spent more than a decade studying promising alternative practices in long-term residential care. She and her team have published and promoted numerous ways in which we can make long-term care safer and better for residents and staff.
Since the COVID-19 pandemic hit, Armstrong has been highlighting how the profit motive in so much of Canada's long-term care facilities skews the care that is provided. While governments pay lip service to her team's short-term recommendations, such as limiting workers to only one location and ramping up testing to determine who is sick, there is a marked reluctance to go beyond that.
What is the most important recommendation they make? It is to ensure that profit is taken out of the system precisely so that the care on offer isn't big-box institutional care. In fact, international research shows that we can do much better: with public funding and ownership, we can have many and diverse models of small-scale well-built care centres, with families and residents able to engage with well-paid and permanent staff who have the time and ability to build and sustain relationships with them.
In the midst of the pandemic, governments are scrambling to provide wage premiums and PPE; but we need to focus on the conditions of care and work. Money may not even be the most pressing issue. It is about the political will to make a drastic change that creates a unified system of care. Prime Minister Justin Trudeau noted the expected round of negotiations about health transfers has been post-phoned from May, but that "We will, of course, be there to have conversations about increasing supports to the provinces for health care."
The PM even floated the notion of expanding the Canada Health Act to cover long-term care, but it didn’t take long for him to walk that back: in a few days, Trudeau, started repeating the line that care provision falls under provincial jurisdiction.
There is no reason why the federal government cannot add targeted funding for long-term care with strict conditions about meeting national standards to the Canada Health Transfers. Yes, it will be up to the provinces and territories to establish and implement the standards. We have long had an asymmetrical model of federalism which allows Quebec to manage its own affairs. There is no earthly reason why long-term care cannot have national standards under such a model.
The one thing that should be non-negotiable in any new federal funding arrangement is that we cannot continue subsidizing private for-profit corporations in the sector. While residents may be exposed to the same levels of infection in for-profit and public long-term care residences, the data is clear that the death rate is far higher in for-profit facilities.
Corporations should not be able to skim off the money that flows from our governments for substandard care. It is no secret that long-term care homes in the for-profit sector spend less money on the care of their residents than do non-profit homes. About half the long-term care beds in Canada are run on a for-profit basis, and a number of large corporate actors are in the business of providing both long-term care and retirement homes purely to maximize profits. Data from the government suggests that the vast majority of "nursing and residential care facilities" in the private sector are quite profitable.
We need to talk about how our resources are spent. Consider B.C., for instance: when the province instituted measures to stop health-care workers from working in more than one care facility, the cost was estimated to be an additional $10 million a month. But as Andrew Longhurst and Kendra Strauss write:
"The top-up will go to some employers who are already funded to pay the unionized rate ... In practice, the top-up means these operators will be rewarded for over-charging the public. Instead, they should be compelled to pay the unionized wage rate -- without additional funding -- and to become part of the public sector labour relations structure ... "
We need to end subcontracting and fracturing of care -- the Globe's account of the COVID-19 outbreak at the Lynn Valley Care Centre mentions Carecorp Seniors Services, a dietary aide subcontractor; Pro Vita Care Management Inc., a care aide subcontractor, and WestCana Services Inc., contracted for housekeeping -- just one ridiculous example of the way in which the system has been compartmentalized beyond belief. The privatization of care cannot continue if we want a cohesive system that is focused on creating livable and safe environments. The cooking, cleaning, caring, nursing and therapeutic team should all be under the employer with decent working conditions that enable them to provide the care they can and want to for their vulnerable residents. This is the way to ensure that residents feel at home with their carers as opposed to watching a revolving door of temporary agency staff or subcontractors come in and out everyday.
There is widespread recognition that change is needed, but there is already heated debate about the direction of this change. The Canadian Association for Long-Term Care -- which represents employers and management -- would like more money. A CBC article earlier this month reported the CALTC argues the problem is the federal government has not funded them adequately to build better structures to house clients -- but what this article misses is that Jodi Hall, who speaks for the association, is also executive director for the New Brunswick Association of Nursing Homes, which engaged in a vicious battle with CUPE nursing home workers in New Brunswick over wages and working conditions. John Ibbitson, always reliable in his championing of the private sector, suggests long-term care insurance, writing that calls from organizations like the Canadian Labour Congress to nationalize the sector are premature. Mr Ibbitson is wrong; we don't need any more studies. The topic has been studied for decades. We have the solutions; indeed, we've had solutions for years, but no one was listening. But maybe now we will see action from the government.
Don't be distracted by academic debates about whether the federal or provincial and territorial governments are responsible for long-term care. It is no different from health care in general -- we need the federal government to step up with resources and enforceable national standards. This can be done through the expansion of the Canada Health Act, and maybe even through regulatory change.
The only real criteria ought to be that resources for long-term care -- whether it is direct federal transfer funding, funding from other levels of government (such as provinces and territories or municipalities) or even private citizens' own co-payments -- should not be diverted to private profits. The money should go toward providing excellent care by hiring the staff needed and supporting them in their work. Provinces and territories can figure out how to implement these national standards and principles. Municipalities, many of which already fund some long-term care, also have a role to play, both in funding and perhaps in terms of service provision. It should be up to the federal government to set the standards, provide base funding and then facilitate provincial, territorial and municipal governments to figure out how to phase out for-profit operators. The end of private profit in long term care is a critical part of building a better and more livable system.
Archana Rampure usually lives and works in Ottawa. Before the pandemic, she was going to be travelling and writing from Latin America, Spain and India in 2020.
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