Last week there were two thoroughly scathing reports on long-term care in Ontario.
Both the auditor general and the Commission on Long-term Care detailed similar problems in this sector—problems that were exaggerated by COVID-19 but identified long ago.
Both reports provide specific recommendations which, when combined, produce a comprehensive path to change. As the commission wrote in its interim report, we don’t need more studies. What we need is political will to make long-term care a safe and rewarding place to live, work and visit. And we need to do it now.
The commission’s report calls for person-centred care, making it clear that staffing and leadership are at the core of this approach. As we have been arguing for well over a decade in our international “Reimagining Long-Term Residential Care” project, the conditions of work are the conditions of care.
Those conditions include more staff, a better mix of staff, more full-time staff, employment at a single site, pay equivalent to hospital staff, continuous in-person training at work—on work time, more autonomy for staff, and physical environments that make good care possible.
This would apply to everyone paid to work in the home and not only the nursing staff. It would also include families and volunteers.
The commission makes it clear that unless working conditions are addressed, it won’t do much good to educate more care workers because it will not be possible to keep them in the job.
Leadership that is responsive, informed, ready to adapt quickly and communicates continually, as well as clearly, is an essential component to meet these conditions.
The commission not only recognizes all of this, as many others have in the past, it also provides details, informed by evidence, on how to address these conditions. For example, the report says that in meeting the minimum hours of nursing time per resident, per day, the data must count worked hours and must not include the new resident assistants who have very little formal training.
The commission makes it clear that unless working conditions are addressed, it won’t do much good to educate more care workers because it will not be possible to keep them in the job. We can address these conditions right now, although some of the changes in the physical environment will take longer.
Unlike some of the culture change models intended to transform nursing homes, the report acknowledges and addresses the diversity in Canada. It calls for culturally appropriate care that attends to language, spirituality, sexuality, Indigeneity, and race/ethnicity.
One strategy it suggests is the promotion of more population-specific homes and smaller units within homes to accommodate such diversity.
In calling for a more integrated system, the commission states several times that although we do have to invest more to support living well at home, we will continue to need long-term residential care. It emphasizes that links with hospitals and public health agencies are vital, especially around infection control.
We agree that these links are critical, as is attending to the increasingly complex clinical needs of residents. However, it is equally important to avoid the over-medicalization of long-term care homes and to support living well in these homes.
Like so many other reports, the commission calls for effective accountability and communication with the public. As it states, current measures and processes are inadequate. The report recommends:
- Restoring full inspections—with legislative teeth,
- Involving staff, residents and families,
- Making reports public, accessible and more timely,
- Developing better indicators that are recorded more frequently,
- Protecting whistle blowers,
- And enforcing regulations through, if necessary, the removal of licenses,
- At least as important is the requirement to report on progress annually.
These are all important, as is the need to report compensation for all staff. The commission does not see accreditation as the solution but does encourage the province to participate in the development of national standards.
All these recommendations can and should be implemented now.
However, there are some missed opportunities. The commission does not go as far as the U.S. does in requiring the regular submission of payroll data that can help track compensation and hours worked.
There are also some missteps. For example, the commission recommends allowing surveillance video in private rooms. While this is frequently promoted as a way to keep an eye on staff—which is, in itself, contentious—it also means residents have no privacy either.
The commission’s stance on for-profit delivery is particularly problematic. It documents the list of indicators that show a pattern of lower quality care and working conditions in for-profit homes.
The commission recommends allowing surveillance video in private rooms. While this is frequently promoted as a way to keep an eye on staff—which is, in itself, contentious—it also means residents have no privacy either.
On this basis, it recommends that the province no longer give licenses to homes focused on profit but, at the same time, it supports those privately owned homes that are mission-driven. There is no obvious guidance on what constitutes “mission-driven” nor was evidence provided that shows such homes escape the issues already associated with for-profit homes.
Acknowledging that the bidding process favours for-profit firms, the report recommends that municipalities and the government provide supports to non-profit and municipal homes in the bidding process as a way to begin addressing this unfairness. However, it does not provide recommendations on the bidding process itself.
Even more problematic is the recommendation for public/private partnership on the construction and ownership of homes. There is a considerable and growing body of research indicating that such partnerships in health care frequently mean higher costs and lower quality buildings, with less public control over the design. The commission recommends that the government own the buildings after years of public payout, but then we may be stuck with old buildings.
Moreover, we could find virtually nothing about the contracting out to for-profit firms of services within homes. There is a discussion of physical design that could include smaller units with kitchens and laundries in each. However, there is no discussion of contracting out to for-profit firms to provide the food and housekeeping services that are so essential, not only to infection control and basic needs, but also to the quality of care and of life.
The report documents multiple government failures, especially related to the slow timing of their responses, the inconsistent communications and directives, and the cancelling of inspections. But the real question is: Will the government act quickly on the commission’s recommendations?
Such contracting also undermines teams and continuity of care, as well as the quality of the work. The contracting out of management services in non-profit and municipal homes is left unaddressed, even though such contracting can bring the profit motive into the home.
The report documents multiple government failures, especially related to the slow timing of their responses, the inconsistent communications and directives, and the cancelling of inspections. But the real question is: Will the government act quickly on the commission’s recommendations?
It makes clear that we cannot wait four years for four hours of direct care per resident per day. Indeed, we can’t wait to have any of these conditions addressed, not only in Ontario, but also in other jurisdictions, including the federal government.
It will cost a lot but it must be recognized that long-term care is an investment in infrastructure, just like a highway. However, investing in care brings much more to the most vulnerable, namely the residents, the staff, and their families.
As the Romanow report on the future of health care put it, it is a matter of values. With such reports as a guide, there is no excuse for failing to act—and act quickly—on our values.
