Read Part 1 of this look into the conditions of long term care in Ontario here.
By Zaid Noorsumar
On Jan. 23, 2007, 73-year-old Betty Moseley-Williams testified to the legislative standing committee about Bill 140, the Long-term Care Homes Act.
Moseley-Williams, who had worked as a nurse for 50 years, harkened back to a conversation with her dying sister over a decade earlier as they planned her funeral. A teary-eyed Moseley-Williams was consoled by her sister, Mary:
“Betty, don’t cry. I know where I’m going. You don’t have any idea; my worst nightmare is that I will sit with paper panties in the hallway with a blanket half covering me, tied in a chair.”
“I’ve thought of that a great deal over the last 11 years,” testified Moseley-Williams. “I have to say that Mary’s worst nightmare became reality for all of us.”
Moseley-Williams went on to speak about the gross indignities residents faced in the midst of declining care standards.
“When a person sits in their own urine or feces for long periods of time,” she said. “The resulting skin breakdown should not surprise anyone, and it raises the question: Is this abuse, and abuse by whom?”
The minimum care standard
The standing committee heard from many other people who told similar tales of neglect and degradation. Representatives from several unions, caregivers, and others who were intimately familiar with the industry appealed to the compassion of Ontario’s lawmakers.
There was a consensus among advocates on the solution: Ontario needed a minimum care standard of 3.5 hours. The standard refers to the number of hours of direct nursing and personal support caregivers provide to each resident on a daily basis.
In 2007, based on government data, residents were receiving about 2.8 hours of daily care. Latest figures from 2016 show that number has gone down to 2.71.
The calculation of required hours hinges on the complexity of the resident population. An aging population requires more direct hands-on care, or “touch time.”
Aside from the changing demographics, the complexity of care in Ontario’s nursing homes has risen due to over two decades of health care cuts and closing of hospital beds, which is well-documented in the Ontario Health Coalition’s 2019 report: Situation Critical. Patients with complex needs have been transferred from hospital beds ($450-500 per day) to long-term care beds, which are funded at a much lower rate ($170).
The minimum care standard was first legislated in Ontario by the NDP government (2.25 hours) as it went about reforming the sector and bringing all nursing homes under the ministry of health umbrella.
In 1996, the Conservative government got rid of the standard in an effort to reduce “red tape.”
In 2003, Liberal Premier Dalton McGuinty promised to implement a minimum care standard. But in 2007, the government broke that promise by not including it in the Long-Term Care Homes Act despite the urging of those who knew the industry best. Although the Liberals appointed an expert to produce a report on the issue in 2008 – the result of which was more inaction – and promised in 2017 that direct care would rise to four hours by 2022, they ultimately failed to reinstitute the minimum care standard regulation.
Consensus at Queen’s Park?
In October 2016, the NDP introduced Bill 33: Time to Care Act, which in accordance with growing medical complexity of residents, advocated a minimum of 4.1 hours of daily care per person.
This new standard of care would also require an injection of funding to adequately raise staffing levels.
France Gelinas, the NDP MPP who introduced the bill, pointed out in the legislature that personal support workers had about five to 10 minutes to help residents with their morning routine.
“That includes helping the person get up, wash, get dressed and, like most of us, go to the bathroom,” Gelinas said in a debate on Nov. 2, 2007.
She asked the Speaker of the House and her colleagues if they could imagine going through that routine in 10 minutes.
“Now imagine that you are 92 years old and you have mobility challenges,” she said. “And you have to get this done, every day of your life, within 10 minutes of getting up.”
Gelinas finished her speech by reading out a petition signed by over 70,000 people – thanks to the work of CUPE – calling for a minimum care standard.
John Fraser, who is currently the interim leader of the Liberal party, lauded Gelinas’s initiative and said he’d support the bill.
Others joined in enthusiastically – Liberals, Conservatives and New Democrats alike passionately spoke about their commitment to seniors and endorsed the legislation.
The second reading passed 44 to zero, with the matter being referred to the standing committee.
And then – nothing. The committee meetings never happened.
The Time to Care Act was reintroduced by NDP in July 2018 after the Conservatives came into power. It has yet to be discussed in the legislature despite the Tories’ ostensible support for the measure while in opposition (and amnesia about the record of their own previous government).
Why wasn’t it passed?
The weight of evidence suggests that the for-profit homes and their lobbying efforts have heavy influence over government as laws and regulations have generally been well aligned to their interests. In other words, profit-making is taking precedence over the lives of one of our most marginalized groups.
Long-term care homes are publicly funded through taxpayers, whether they are for-profit or not. However, peer-reviewed, academic research has shown that for-profit nursing homes allocate less staff for residential care (and thereby provide poorer quality of care).
The Ontario Long-term Care Association advocates for privately-owned facilities, although it also represents some non-profits and municipal homes.
The OLTCA’s board of directors includes representatives from multinational corporations such as Chartwell, Extendicare and Sienna Living.
In 2012, Extendicare paid $38 million to the U.S. Department of Justice for “billing Medicare and Medicaid for materially substandard nursing services that were so deficient that they were effectively worthless.”
The OLTCA explicitly stated in its 2016 report (p. 9) that it didn’t support the NDP’s minimum care legislation.
The advocacy group Ontario Health Coalition’s 2002 report, Ownership Matters, revealed that private long-term care homes donated $336,545 to the Tories and Liberals from 1995 to 1999. The NDP in contrast received $2,000.
My own data collection based on available records from Elections Ontario (and the National Post’s database) shows that between 2007 and 2016, OLTCA along with other private corporations in the industry donated at least $600,000 to Liberal and Tories. Due to incomplete data, the actual figure is most certainly higher.
Between 2013 and 2015, the OLTCA alone donated at least $92,202, with well over half the money going to the Liberals. The Conservatives received $22,965 and the NDP $12,495.
In 2001, CBC reported that companies that donated the most money to the ruling Conservative party back then seemed to get the contracts to build more government-subsidized beds.
Since 2003, when the Conservatives left office, the proportion of privately-owned nursing homes has remained virtually the same. At present, 58 per cent of homes are for-profit, 24 per cent non-profit and 18 per cent municipally-owned.
“If [Liberals and Conservatives] are worried about their private friends getting profits out of the health care system,” says Teresa Armstrong, NDP’s long-term care critic. “Then they’re not going to want to make sure that we legislate that time to care. Because that means more hands on deck, putting more money into front-line care.”
The OLTCA: Ontario’s nursing homes have made great strides
Considering the wretched conditions in nursing homes – exposed by multiple studies as well as numerous media reports – one would think that the OLTCA, which claims to represent all types of nursing homes, would speak about that in its annual report.
But although the association calls for more funding for staff – even for-profit homes realize that extreme violence is not good for business – there is no mention of violence.
In fact, there is no mention of the working conditions. There is no acknowledgement of the pain and suffering experienced by seniors.
Instead, the OLTCA’s 2019 report says “long-term care homes across Ontario made great strides in improving quality of care over the five-year period between 2012-2013 and 2016-2017.”
This extraordinary claim is based on a metric termed Qindex, which the OLTCA says it developed in partnership with the University of Toronto. Using this assessment tool, the OLTCA makes another questionable claim – that there isn’t a qualitative difference between privately-owned and non-profit homes.
Qindex is based on data focusing on nine factors including use of anti-psychotic medication, pressure ulcers, number of times people fall down, use of restraints, worsened physical conditioning and depression.
Pat Armstrong, a York University professor who has been researching long-term care for over a decade, questions the value of Qindex as a reliable measurement tool.
“The nine indicators are very limited set of indicators. And who gets to record them and how is a big question,” she says, referring to the difficulty in measuring depression, pain and “worsened physical functioning.”
Restraint use, anti-psychotic use and pressure ulcers can be quantified, she agrees.
However, even though there’s an expert consensus that anti-psychotics should be minimized, and their reduced usage over the years is certainly a positive outcome, that doesn’t necessarily reflect an improvement in overall quality of care.
Reduction in anti-psychotic medication means residents act more aggressively, according to Sue Moore, a registered practical nurse and president of CUPE local 3014.
Unfortunately, she says, the appropriate reduction in medication hasn’t been complemented with increased staffing.
Even a metric such as “falls” can be misleading, according to research Professor Armstrong’s research. In order to reduce people falling down, nursing homes can conveniently place people in wheelchairs, which in turn can lead to degeneration of muscles and actually worsen their health.
“We have more verified complaints from for-profits compared to not-for-profit homes,” Armstrong says. “We know that [for-profit homes] tend to have lower staffing levels. And given what we know about staffing levels and their impact on care, I think we have to take this Qindex with caution.”
OLTCA and University of Toronto’s dubious partnership
The claims originating from the use of Qindex contradict numerous academic studies – including Staffing in Ontario’s Long-Term Care Homes: Differences by Profit Status and Chain Ownership, which was approved by U of T’s research ethics board.
The reference to Qindex and the claim about the quality of for-profit homes is attributed in the OLTCA report to a 2019 article in Healthcare Quarterly – which the long-term care association hasn’t been willing to share with me. It’s currently “in press.”
The article in question was written by Andrea Wilkinson, Vinita Haroun, Tommy Wong, Nancy Cooper and Mark Chignell.
Chignell and Cooper are faculty members at U of T. Cooper, however, is employed by as an executive director at the OLTCA. Haroun and Wong are also OLTCA directors, while Wilkinson conducted a fellowship with the for-profit lobbying group.
Considering that OLTCA has a vested interest in the profitability of corporations such as Extendicare, Revera and Sienna Living, how reliable is the research conducted by its directors?
Is it even conceivable that OLTCA’s research would compromise the interests of its influential members?
In an emailed statement, Elizabeth Church, U of T’s spokesperson, referred me to U of T’s policy on preventing “undue influence on education.” However, she didn’t answer pointed questions about conflict of interest and ethics.
I pressed for more specific responses, and requested an interview to better understand the university’s viewpoint, but didn’t hear back.
I also raised the point of OLTCA director Nancy Cooper’s employment at the well-reputed Dalla Lana School of Public Health, which purports to “improve health services on a system level – on a sustainable foundation of public good and social justice.”
In an emailed statement, Church wrote, “U of T has a long history of partnerships with industry, and partnering with health sector and other industry leaders to help educate and train our students. In order to effect change to improve health and safety, it is essential to understand and engage with organizations in the sector.”
Do we care to act?
The OLTCA has advocated for increased staffing and government funding, both of which are essential. And it’s true that successive governments have failed to invest sufficiently in the sector.
But when the government is funding privately-owned nursing homes, it means scare resources that should be diverted to care are instead subsidizing business.
“[Privatization] is not the way to give quality of care,” says the NDP’s Teresa Armstrong. “We should take our precious healthcare dollars, and put them into front lines, where they belong, to get quality care for residents.”
And while for-profit homes have the lobbying clout to advocate for their cause, Ontario’s most vulnerable people – seniors, people with mental health issues and a predominantly female, lowly-paid workforce – do not.
“The problem is that both the workers and the residents are people with little or no political voice,” says Jim Brophy, professor at University of Windsor and co-author of the Breaking Point study. “They’re just off the map, and the workers are afraid to speak out.”
In such an environment, who will be speaking up for those living on the margins, and how and when? Is it time to care yet?