A pill trolley rattles urgently as it makes its rounds in one of Ontario’s many long-term care homes. The support worker pushing it looks visibly exhausted, while a nurse practitioner moves stressfully under the imperatives of time and patient needs, tending to the unwashed, unshaved, undressed, unturned and unfed.
Ontario’s long-term care homes, which provide 24-hour nursing services to chronically ill residents who require some form of basic assistance for daily living, suffer intolerably from an understaffing crisis.
As the pioneer of privatized care in Canada, Ontario has opened the doors for a corporate takeover of long-term care homes, resulting in chronic understaffing by profit-seeking multinational providers.
Those in Ontario with the good fortune of longevity must brave the consequences of this increasingly corporate care. For residents, this means that staff are so busy as to be unreachable. Meanwhile the owners – the corporate directors and proprietors of the homes – continue to extract a profit, a vital portion of which is public money funnelled from government subsidies urgently needed for patient care.
In an effort to counter this deliberate understaffing, a coalition of forces – unions, residents and their families – have been principled in their calls for an enforceable average of 3.5 hours of care per resident. Ontario is the only province without such a law. The currently triumphant opposition is the corporations whose profits are based on the ability to keep staffing levels as close to zero as possible.
Despite the understaffing crisis, multinational providers such as Extendicare, whose workers reported 36 understaffed shifts in one month, have no scruples about advertising themselves to investors as an asset that “generates strong cash flow” – cash flow derived from public money that ought to be allocated for long-term care staff.
Long-term care is a burgeoning market across Canada. This is particularly true in Ontario, with over 75,000 long-term care residents. Of these residents, 75 per cent of whom are women, 73 per cent have a form of dementia, 72 per cent need assistance with mobility and 86 per cent have some degree of incontinence.
The need for reliable and safe levels of staff clashes irreconcilably with the imperative of a corporate provider to expand its quarterly earnings. Ontario’s long-term care sector is now the most corporatized in the country, with six multinational corporations having secured 76 per cent of the market. Staffing levels in Ontario rank below all provinces save for B.C. The connection between privatization and understaffing is neither spurious nor shocking.
The making of Ontario’s long-term care market
During the recession of the early 1990s, the debt obligations of the Ontario government became intractably high. As part of sweeping cutbacks in public services, Bob Rae’s NDP government began to delist the services provided by hospitals, which are covered under the Ontario Health Insurance Plan.
The ground watered by Rae quickly bore fruit for multinational real estate investment trusts, looped and linked as they were with Ontario Conservatives in the 1996 election. In exchange for lavish contributions to their campaign, the Tories began the process of contracting out services as recommended by the Health Services Restructuring Commission. The three corporations that gave donations in excess of $22,000 – Extendicare, Central Park Lodges and Leisureworld – received roughly 40 per cent of the contracts by 2001. Thus began the conversion of Ontario’s long-term care homes into coveted commodities and the diminishment of staff to boost the profitability of these assets.
In 1994 there were 74.4 registered nurses per 10,000 people; by 1999 there were 67.6. The corporations that made seemingly low bids for contracts did so only under the stipulation that they could cut their staffing levels to recoup profits. Then-premier Mike Harris erased the legislation that required a minimum of 2.25 hours of care per resident, ensuring that profits would rebound sufficiently.
Ontario Premier Dalton McGuinty, appearing more benign than the Tories, was elected on the grounds that he would reverse the Tories’ assault on the public sector. Yet the Liberals have actually managed to contribute less to Ontario health care than their Tory predecessors. Between 2003 and 2007 health-care spending increased by 30 per cent, whereas between 1998 and 2003 the same indicator increased by 43 per cent.
In 2007 Premier McGuinty finally appeared to be honouring his health-care promises and tabled Bill 140, which become the Long-Term Care Homes Act in 2010. After three years of ostensibly fruitful consultations with a vast number of unions and advocacy groups like the Ontario Health Coalition, the McGuinty government had everyone convinced that a minimum of 3.5 hours of care would find life in black letter legal code.
Yet the chief consultant for the provincial government, Shirley Sharkey, abruptly abandoned the minimum standard and advanced toothless and non-binding guidelines, which the corporate community has blithely ignored. Sharkey and Premier McGuinty disregarded the near-universal calls for minimum standards of care, as the resolution to the understaffing crisis was entirely contingent on an amendment to Bill 140 that would give the public the power to set staffing standards.
The real crisis in provincial health care finances
The understaffing crisis in Ontario’s long-term care homes is bred in the bone of privatization. Based on the assessed needs of a home’s residents, the government provides a per diem subsidy, which currently stands at $152.94 per resident per day for services.
Government funding goes into four envelopes in each private or public home: staffing, food, services and accommodations. The accommodations envelope is the only envelope from which a corporate home is not obliged to return to the government any unused funds. In other words, every unused dollar in this envelope is rendered into profits. Managers, then, seek to move costs, like incontinence supplies, into other envelopes to free up potential money for profit.
Such managerial manoeuvres require approval by regulatory bodies, such as Ontario’s unelected Local Health Integration Networks, which are composed of Liberal and corporate patronage appointees. The cozy relationship between corporations and public officials makes this a much simpler affair than it ought to be. Without a legislated standard, this sort of double-dealing with envelopes is as unpreventable as it is dangerous.
The consequences of corporate care in Ontario are felt by both residents and workers. Residents who suffer from cognitive impairments, making language and social connections and abstract thought difficult, register their frustration against the first hurried staff member who eventually gets around to tend to their needs. One York University study, “Out of Control: Violence Against Personal Support Workers in Long-Term Care,” found that nearly half of all staff can expect to be assaulted at least once a day.
Ontario is the pioneer of this style of “care,” where exploitation of staff and neglect of residents thicken the dividends for corporate owners. Other provincial governments are, frighteningly, beginning to follow suit.
But as nurse-to-patient ratios grow unsustainably high, front-line caregivers, along with the Registered Nurses’ Association of Ontario, CUPE, the Ontario Public Service Employees Union and the Ontario Health Coalition, have entered into a struggle to stop corporate providers from misappropriating public money for private profit. Central to their campaign is the call for a minimum standard of 3.5 hours of daily care per resident, without which corporate providers face no imperative to provide adequate staffing.
This battle goes beyond the elderly. Since even the sprightliest of us will invariably face the trials of aging, we ought all to be concerned with restoring accountable, publicly provided long-term care across Canada.
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