Written by Geoff Norquay for Policy Magazine. Click here to read the original.
The number of deaths from the COVID-19 virus that have occurred in Canada’s long-term care (LTC) homes has been a scandal within a catastrophe. The systemic problems exposed by that fatality rate will require, as Prime Minister Justin Trudeau has indicated, a critical mass of political will and collaboration between Ottawa and the provinces.
The shocking stories of residents abandoned by caregivers and left in unmade beds and unlaundered clothes is one of the more scandalous disclosures of the pandemic. A November 24 research note by the Library of Parliament reports that “75 percent of total deaths” from COVID in Canada are in LTCs and seniors’ residences. Among overworked caregivers, the report finds that “Nearly 90 percent are women” while 70 percent are themselves over 40, and 50 percent are immigrants. At least 25 percent have more than one job and fully 65 percent “report having insufficient time to complete tasks” at hand.
The federal, provincial and territorial governments have been struggling to respond to this crisis, attempting to meet public and stakeholder demands to fix the system and create national standards. They have been using established practices as well as new approaches within a creaky federal-provincial system that has complex constitutional and historical roots. Bringing substantive reform to the LTC system will require a new collective will to work together, plus significant creativity to solve its many challenges.
The problems of the LTC system are focused in six related areas:
- Woefully inadequate home care, which is necessary to keep the elderly in their communities and to lessen the demand for long-term care;
- Backlogged and rapidly growing demand for LTC beds;
- Rapidly rising costs of both home care and LTC due to Canada’s aging population;
- The urgent need to replace outdated physical plants that currently force thousands of residents to be housed in multi-patient wards;
- Inadequate standards of care within LTC facilities that result from persistent understaffing, low pay and minimal training guidelines for nurses, personal care workers and attendants; and
- Abysmal inspection and enforcement of standards at the provincial level.
It is important to note that these challenges are significantly interdependent; attempts to fix one will only be truly successful if the others are also addressed. In addition, the complexity and cost of addressing these issues mean they will take many years and many billions of dollars to adequately address.
In 2017, the Organisation for Economic Co-operation and Development noted that “Canada spends at one extreme of its OECD comparators in spending 87 percent of its long-term care dollars on care in designated buildings and only 13 percent on home and community-based care.” This imbalance pushes too many elderly Canadians toward higher levels of institutional care due to the shortage of independent living supports in the community. As a result, an estimated 40,000 Canadians are currently on waiting lists for long-term care.
In Budget 2017, the federal government committed to transfer $6 billion over 10 years to the provinces and territories for home care, but the current and future needs far outstrip that investment.
A 2019 National Institute on Aging report estimated that the public costs of home care and nursing homes were $22 billion in 2019, but these costs are “projected to grow to $71 billion by 2050 (in 2019 constant dollars).” The Conference Board of Canada forecast in 2017 that Canada will need an additional 199,000 long-term care beds costing approximately $64 billion in capital spending and $130 billion in operating spending between 2018 and 2035.
While these issues are being addressed, multiple-occupancy LTC wards need to be phased out in favour of double and single occupancy rooms. Almost one-third of Ontario’s 77,000 LTC beds are configured in multi-patient wards and the province has recently announced funding to begin to address this challenge.
How can these added costs be accommodated within the federal-provincial framework? There is an existing funding model to enable this to occur—the bilateral agreement approach already used for home care and mental health—in which provinces agree to designate new federal funds toward investments in specific program areas. In addition, if LTC facilities were made eligible for funding under Infrastructure Canada’s Building Canada Plan, the federal government would have an additional avenue through which to assist with provincial and territorial capital costs.
The impacts of the pandemic on LTC facilities have highlighted the urgent need for more, better trained and higher paid staff and the creation of more stringent standards of care, all mandated by tougher provincial regulations.
Provinces also need to up their collective regulatory games immediately. In Ontario and Quebec, the pandemic exposed the current inspection regimes for LTC facilities as intermittent, incompetent and useless. Improved regulation must include much tougher sanctions for homes that do not deliver the required standard of care. Australia has a refreshingly direct way of enforcing compliance—it cancels the licences of offending facilities and puts them out of business. Provinces need to adopt this approach.
The NDP, unions and some health care advocates see the public administration principle within Medicare as the route to ending private sector ownership of nursing homes. The number of COVID-19 deaths in privately-owned facilities is held out as the principal reason to ban the profit motive from long-term care.
The steepest barrier to creating a wholly public and charitable LTC sector is the cost of the resources necessary to make that happen. The sobering reality is that the mountain of dollars required to end private ownership would not create one more LTC bed at a time when thousands are needed. Surely the answer is to create tougher standards of care for patients in all LTCs and enforce them.
The operational and regulatory issues at the center of the LTC crisis are deeply within provincial jurisdiction and the federal government has very little direct experience or expertise in their details. This means the national standards the prime minister has repeatedly called for will need to be collaboratively created between the provinces and the federal government. In addition, “given the systemic nature of the LTC problems revealed by COVID-19, a systems-wide approach is required to clarify existing legislative and regulatory authorities under the (Canada Health Act).” To work toward solutions, collaborative federal-provincial tables need to be established urgently to begin to tackle these issues.
The recent fall economic statement included a federal offer of up to $1 billion to help provinces and territories with long-term care, with funding “contingent on a detailed spending plan…and conditional on provinces and territories demonstrating that investments have been made according to these spending plans.” These requirements are backed by legislation, which means payments will only be made by the federal government on receipt of proof from the provinces that specific commitments have been realized. This raises conditionality to a new level, but it does open the door to federal help in solving the provincial operational challenges.
Quebec has already rejected national LTC standards, but the time-honoured practice of asymmetrical federalism provides a route for the objectives of both sides to be achieved. In the past, the province has loudly decried federal interference in its jurisdiction over health and social policy, then developed its own set of roughly parallel standards and taken the federal money. We will see if a similar work-around can be developed to accommodate the new federal requirements.
The challenges involved in fixing long-term care in Canada are larger than any single level of government. Given the range of issues the country will face coming out of the pandemic, it’s going to be hard to find the billions of new dollars necessary for investment over many years, but a way must be found.
This much is certain: the many thousands of relatives and friends of the more than 8,600 seniors who have died in LTC facilities as of the end of November will have no patience for federal-provincial squabbles over money, jurisdiction or accountability. Their simple demand will be that long-term care be fixed; they will care little about who does it, who pays for it or what it will cost.
The memory of those who have died as a result of this very Canadian public policy disaster deserves no less.
Contributing Writer Geoff Norquay is a principal with the Earnscliffe Strategy Group. He is a former social policy adviser to Prime Minister Brian Mulroney, and was later communications director to Stephen Harper in the office of Leader of the Opposition.