Long Term Care: Fatally flawed system demands fundamental change

Given that seniors are at greatest risk, as evidence from China shows, and those living in long term care homes are among the most vulnerable, it should be no surprise that the first cluster of illnesses, and the first fatality, related to the COVID-19 virus appeared at the Lynn Valley Care Centre in North Vancouver. The death toll stood at 11 late last week, with more than 40 other residents testing positive for the virus, along with 21 staff members. 

This morning, there was news of nine deaths at a nursing home in Bobcaygeon, Ontario. Half of the staff were reporting symptoms of the coronavirus as of Friday night.  

Long term care residents and health care workers are caught in a terrible situation that has been years in the making. The virus is moving through facilities in the same way that it has around the world, preying on vulnerabilities that are well known: a growing reliance on a subcontracted labour force whose members work multiple jobs to make ends meet, and conditions of employment—fewer workers, more part-time hours, high turnover, heavy workloads, increasing levels of violence, poor wages and benefits—that work against quality care and recruitment. 

Canada’s deeply flawed long term care system
Health-care workers paint a picture of a system that was already struggling before the coronavirus hit, drained and strained by austerity measures over the past two decades. In the long term care sector, we have actually seen a decline in the number of beds and long term care facilities, despite the steady rise in the population of seniors. 

Governments intent on containing health care costs and improving efficiencies have turned to private sector delivery and for-profit managerial strategies—strategies that have ended up delivering lower quality care at greater expense, while shifting more of the costs and labour involved to seniors and their families.   

The pandemic is now exposing the graphic weaknesses of our current system and significant disparities in levels of quality care—both between and within provinces. The failure over the years to provide enough beds to meet the growing need means that the majority of those now in homes have been diagnosed with dementia as well as a host of chronic illnesses. At the same time, a significant number of the homes were not built to accommodate people with heavy health care needs, making physical distancing all but impossible. 

Many long term care homes of all types have contracted out food, laundry and housekeeping services, bringing outsiders into the home on a daily basis and limiting managerial control over the quality of this work. Many homes that receive public funding have unionized staff, which means there is some protection against job loss and some sick leave benefits. But this is usually not the case for contract care workers and those employed in contracted services who, in many instances, are treated as self-employed contractors themselves, responsible for their own training and protective equipment. 

Low staffing levels have long been identified as a critical problem in the sector. Although there are requirements to have one registered nurse on staff or on call, for example, only a few jurisdictions set minimum staffing levels and those that do set them well below the four hours of direct care per resident per day set out the literature—a figure that is itself out of date and should be raised given the needs of residents today.  

Precarious conditions in long term care
Care work in nursing homes is overwhelmingly carried out by women, most employed as what are variously termed personal support workers or care aides, many of whom are racialized and/or newcomers to Canada. Hundreds of thousands of workers undertake this so-called “low skilled” work that is indispensable to our collective well-being and the well-being of vulnerable seniors. 

For many, the precarious nature of their employment is a fundamental threat to their own health, and leaves residents vulnerable to illness and hospitalization, as we are seeing in real time today.  

Care workers are acutely aware of the impact of their working conditions on the quality of care offered. In a recent survey of Manitoba nurses working in long term care, only 26% rated the quality of care provided in their facility as “excellent”; 58% said they didn’t have enough time to properly care for their patients, and 56% said the staffing levels at their workplaces were inadequate. 

The challenges are greater in for-profit facilities. Study after study continues to show that for-profits tend to have poorer quality of care than non-profits or municipal homes, as measured by lower hours of direct care per resident, number of verified complaints and deficiencies, and resident transfers to hospital. 

Large private chains now expanding across Canada generate sizeable profits for their shareholders through short staffing, and lower wages, benefits, and pensions. Across Canada, for-profit facilities have 34% fewer staff and spend less on direct care than homes under public ownership. A recent report of the BC Office of the Seniors Advocate found that the for-profit sector spent an average of 17% less per worked hour compared to non-profit facilities, and the wages paid to care aides in particular were up to 28% less than the industry standard. 

Caring burden falls to women
With substandard staffing levels, the pressure is on relatives and volunteers to not just provide social support, but basic tasks such as helping residents to eat and dress. Increasingly, families with means hire privately paid companions (another precarious group of workers) to assist with these tasks, while families without struggle to provide needed assistance, living with constant anxiety and worry.

These heavy demands fall largely on women, with often significantly negative consequences for their health as well as for their current and future employment. Almost eight million Canadians are unpaid care providers, roughly half of whom provide support to a parent, in-law or older relative with long term health conditions or age-related issues. Among all caregivers, 32% of women and 28% of men report that they have unmet needs related to their caregiving, and of this group, many experience significant daily stress (36%) and fair or poor mental health (23%). Many of these provide care within nursing homes.

Even now, families are turning down placements in long term care homes after waiting for months, or even years, for a bed to open up because of fear of infection and staffing challenges. At the same time, home care services and adult day programming are being cancelled or reduced in scale—increasing the demands on family caregivers providing support. For those looking after an elderly spouse or relative on their own as many older women do, the loss of home care will have a significant impact on their own health and well-being.    

The time to invest in the care economy is now
COVID-19 demonstrates how economically and socially precarious so many people—and the services they depend on—are. But if long term care—and home support—is low-paid, precarious work provided by women who can’t afford to stay home when they’re ill, it’s because as a society we’ve made that choice. 

In the short term, Vancouver’s health authority is restricting workers and volunteers from providing service in more than one long term care home to help stem the spread of the virus. The Ontario government is throwing caution to the wind and suspending regulations to allow homes to bring in untrained staff and volunteers to assist in the crisis, abandoning the very protections the research shows are critical to keeping residents, staff, families and volunteers safe.

Instead, with the emergency benefits now in place and a new wage subsidy program on the way, this is precisely the time to pivot. Long term care homes should be transforming part-time employment into full-time and offering regular part-time. They should be enhancing training to ensure that all staff—contract or otherwise—are up to date on good practices and have the equipment they need to combat infections.  

Over the long term, we must create high quality jobs in the long term care sector—an objective that is key to advancing gender equality and promoting greater economic security. Offering full-time work at better wages, with good labour and social protections like paid sick leave, is a first key step. This will not only provide greater stability for staff but promote caring relationships with residents which is at the core of good care. 

Governments have a key role to play in setting high national standards for safe, quality patient care, and staffing levels and ratios. This will require dedicated funding from both levels of government to ensure that all people with care needs can access appropriate service and supports without facing usurious costs. And it will involve an end to privatization in all of its forms and the expansion of public non-profit long term care facilities and home care services. 

It is time to make a different set of choices, to place vulnerable seniors and all who rely on social care at the heart of our response to the coronavirus and beyond, and acknowledge long term care as a key part of the social infrastructure we all depend on. 


Author’s note: Thanks to Dr. Pat Armstong, Distinguished Research Professor of Sociology at York University, for her input and review.