Introduction
Since the devastating reports that emerged during the COVID-19 pandemic, much has been said, written, and promised about seniors’ care in Canada. Funding, however, has been slow to follow—and action even slower still. Without a thoughtful, timely balance of both funding and action, the transformation desperately sought by seniors and their families, practitioners, advocates, and scholars will remain more aspiration than reality.
What has been achieved at the federal level is nonetheless notable.
The 2023 AFB called for the implementation of enforceable national standards “aligned with expert consensus on what needs to be done: regulated hours of direct care, improved staffing ratios, a national staffing strategy, increased pay and stability for staff, investments in home care and community-based services.”1 Most significant is the development of national standards for the physical infrastructure of care facilities and the delivery of care at those facilities in January 2022 and 2023, respectively. The Health Standards Organization standards aim to guide the consistency of care, ensure quality of life and dignity for residents, and ensure the well-being of staff; the Canadian Standards Association standards provide guidance on the safe operations of facilities, with a considerable focus on infection prevention and control. Budget 2021 earmarked $3 billion to support provinces in implementing these new standards of care.
Amid growing awareness of the crisis in the health care workforce, efforts to reduce the precarity faced by seniors’ care workers through wage top-ups and retirement funding schemes have the potential to generate positive intersectional impacts.
Overview
Many challenges remain. Among them, the most deeply embedded inequities in the seniors’ care system that are reproduced by neoliberal capitalism: continuing to place profit before people.
The federal government’s approach has been incremental and wary of overstepping on provincial jurisdiction. Its efforts, while necessary, are far from sufficient—leaving the impression of hesitant, piecemeal improvements rather than systemic transformation. The new national standards are entirely voluntary (several provincial legislatures are currently debating whether to adopt them) and lack tangible enforcement measures. The much-lauded bilateral health agreements recently negotiated between Ottawa and the provinces may encourage investing in seniors’ care but they offer few specifics.2 While the agreements acknowledge and move towards several crucial actions called for by advocates and past AFBs (for example, providing wage top-ups for personal support workers and gestures towards “supporting a resilient healthcare workforce”),3 these measures fall short on accountability, enforcement, dedicated or earmarked funding, and the actual dollar amounts committed. Meanwhile, there has been no pushback from the federal government on the increasing shift of public funding to privatized delivery of seniors’ care, despite the large body of evidence—tragically reaffirmed by the pandemic—that private, for-profit care is detrimental to seniors and the workers who care for them.
Rather than striving to enshrine and enforce evidence-based best practices, the federal approach has been to slightly raise the bar to a new minimum. For many seniors’ care workers, already among the most precariously employed and most impacted by the pandemic, the promise of wage top-ups and retirement schemes are a drop in the barrel—all but cancelled out by increases in inflation and cost of living. Without wide scale improvements to working conditions, there will be few incentives for workers to enter or remain in the field, perpetuating staffing shortages that hamper quality care.
While some of these co-ordinated, systemic policies may be forthcoming in the long-awaited Long-Term Care Act, the federal government has so far given few hints as to the content or mechanisms of that legislation—or when Canadians can expect to see it introduced.
Enforcing standards of care
A national co-ordinating body is needed to guide the implementation and enforcement of the standards of care, as opposed to the current ad hoc, voluntary, province-by-province approach. While it is too late to include this caveat in the federal–provincial health agreement (short of renegotiating the entire deal), it is possible to tie future, dedicated funds to the adoption of and adherence to the national standards of care.
Creating a national seniors’ care workforce staffing strategy
A vast body of evidence shows that increased staffing of direct care workers results in fewer negative health outcomes for residents. The COVID-19 pandemic delivered a painful lesson in the consequences of a care workforce that is overstretched and under-resourced. The ripple effects on staff have been exponentially magnified in the aftermath (as such) of the pandemic. They materialize as continued illness, burnout, early retirement, and defection to higher-paid, more secure, or less damaging professions. The combined effect is a decimation of the sector’s workforce. At the end of 2021, there were more than 35,000 vacant jobs in seniors’ care—a drastic increase of approximately 10,000 from the beginning of that year.4
The Canadian Association for Long-term Care has highlighted the extent of the staffing crisis in seniors’ care, and the compounded challenges Canada will need to address to ensure that new and upgraded facilities can be adequately staffed:
Throughout the pandemic, provincial governments in Canada have addressed their own shortages by developing recruitment and retention incentives, however these risk moving the problem either from one health care sector to another, or from one province to another rather than expanding the capacity and pool of staff. […] A pan-Canadian approach is needed to ensure the framework is in place to improve health human resources capacity.5
While a national staffing strategy for seniors’ care should coordinate and collaborate with a wider strategy for health care workers on common challenges, the establishment of a sector-specific strategy will recognize the distinctive nature and needs of seniors’ care.
Collecting and co-ordinating decision-making data
Although the federal-provincial health agreement reached in February 2023 commits to the creation of a “Centre of Excellence” to compile and analyze health worker data, such an initiative should be coordinated with a Canada-wide workforce strategy with specific focus on the seniors’ care sector. In addressing the overwhelming crisis in retention and recruitment across health care fields, such information is necessary to identify areas of greatest need; to align staffing initiatives to local, regional, and national contexts; and, crucially, to understand the challenges faced by current, potential, and former seniors’ care workers. Indicators of workers’ well- being should be used alongside surveys of working conditions and staffing levels.
Rebuilding the conditions of work to transform the conditions of care
Another hard-earned lesson of the pandemic was the cost of precarious, casual, and part-time work for staff in the seniors’ care sector, with as many as 22 per cent of long-term care staff employed at multiple facilities.6
During the pandemic, this precarity had life-or-death consequences as “movement of staff between multiple work sites, insufficient paid sick days and inadequate replacement of sick workers […] became active factors in virus transmission. […] long-term care workers were asked to risk their health, their lives and the well-being of their families while being denied employment security and an adequate living wage.”7 However, single-site restrictions designed to prevent or reduce viral outbreaks left many workers struggling financially.8 The example of British Columbia, where staff were raised to full-time equivalents to compensate for the single-site restriction, led to better outcomes for residents and fewer outbreaks, and it improved the financial, physical, and mental well-being of workers.
The federal government has a generational opportunity to guide and support provinces in building a seniors’ care sector that offers secure, permanent, good-paying jobs and, importantly, in building out interconnected community supports for seniors and people living with disabilities. Moreover, given the demographic composition of the people who work in seniors’ care, home care, and community support, such an investment would have a significant impact in reducing economic inequalities for women, BIPOC, and new Canadians. In turn, residents stand to benefit from deeper, less rushed engagement with staff, and to have their needs met with dignity and compassion.
Actions
Taking these themes—based on decades of research as well as Canada’s recent tragic experiences with COVID-19—as foundational, the AFB will implement the following actions to transform the delivery of seniors’ care in Canada. These actions will weave together the incremental initiatives already set in motion to create a cohesive, co-ordinated, pan-Canadian strategy for seniors’ care.
Following the announcement of the Health Standards Organization standards, seniors’ care expert (and contributor to the development of those standards) Professor Carole Estabrooks cautioned that, “Until there’s a co-ordinated, national-provincial health workforce strategy that includes long-term care, it’s going to be difficult to dig ourselves out of this really profound global emergency we’re in, with respect of the workforce.”9
The AFB will provide for an in-depth, comprehensive, Canada-wide workforce strategy to address the current recruitment and retention crisis, so that qualified personal support workers, nurses, occupational and recreational therapists, dieticians, and other workers who contribute to seniors’ care are available and willing to staff existing and new facilities and services in the community.
Accordingly, the AFB will allocate $25 million annually to establish a national agency to co-ordinate funding, workforce, and standards among the three levels of government with responsibility for eldercare services. These monies will be in addition to the previously committed funding for the implementation of the national standards. The AFB will commit a further $10 million over three years for workforce data collection.
The AFB will invest in converting part-time, casual, and temporary positions into full-time roles wherever appropriate. The AFB will commit $1.2 billion annually to reducing job precarity and retaining experienced workers in seniors’ care.
Additionally, the AFB will commit to building robust, high-quality home care services by expanding the wage top-ups offered to personal support workers in the February 2023 health accord as part of wider efforts to reduce precarity among health care workers in home care (this includes those who provide essential daily care services for seniors as well as for people with disabilities). This measure is estimated at approximately $1 billion annually; including home care workers would increase the top-up from $1.7 billion to $2.7 billion over five years.
The AFB reiterates an investment of $5.7 billion to support an additional 82 million hours of home care for the nearly 90,000 Canadians waiting to access these services. This is an increase of $500 million from the 2023 AFB to account for inflation.
