There is broad consensus that action is desperately needed in the long-term care system. On October 9, the Ontario NDP outlined its plan for reforming long-term care (LTC) and home care should it be elected in 2022. The plan, “Aging Ontarians Deserve the Best: A New, Public and Non-Profit Home Care and Long-Term Care System,” features many bold, innovative, and sound recommendations. It deserves to be taken seriously at Queen’s Park and elsewhere. Several proposals within the plan, however, are flawed and misguided, and they would likely stand in the way of genuine, positive reform for Ontario’s aged. We explore both the positive and the negative here.
Excellent: Emphasizing Family, Home Care, and Community Partnerships.
One of the strengths of the NDP’s plan for senior care is its emphasis on maintaining, partnering with, and strengthening seniors’ own communities, empowering them to deliver care that meets their members’ distinct needs. The proposed improvements to the home-care system to allow more seniors to age in place, partnerships with family and other informal caregivers, protection of couples’ right to live together, and promotion of LTC homes “run by their community for their community” would benefit not just seniors in need of care but also their families, their communities, and Ontario as a whole. The NDP’s plan to transition to small, home-like settings would, if implemented, be another welcome improvement over the institutional approach that currently dominates LTC, and would place Ontario alongside successful international jurisdictions that have made similar transitions.
Good, But Proceed with Caution: Wage Changes in Long-Term Care.
Likewise, many of the NDP’s proposals for improving wages and staffing in LTC are sound, and long overdue. Implementing a permanent boost to wages for personal support workers (PSWs) would help make up for the losses in purchasing power that PSWs have experienced over the last decade. Altering the use of part-time positions and making their compensation package (including wages, benefits, and pensions) comparable to that of full-time workers would help correct the sector’s imbalanced reliance on part-time and casual workers.
Serious questions remain, however, about the wisdom of government fiat for setting wages and working conditions. We have seen how relying on government, rather than healthy and functioning labour markets, can structurally damage normal bargaining for wages and working conditions and thereby hamper workers’ well-being. Regardless, improving the compensation and working conditions of PSWs would make it more likely that the NDP’s planned recruitment program would meet with long-term success.
Indeed, it is imperative that any action taken by government on the staffing crisis include partnership with labour and employers to develop lasting solutions to the sector’s labour-market challenges. Government fiat may be what’s necessary to bring wages back up to an acceptable level in the short term, but recall that it was also government fiat that limited wage increases in LTC for over a decade. Without significant changes to the system, the LTC labour market will continue to languish in dysfunction.
Excellent: Caring as Craft.
We are particularly pleased to learn of the NDP’s plan to develop an apprenticeship program for PSWs. Eight months of full-time schooling—the current requirement to earn a PSW certificate—is a prohibitively large investment for someone who might otherwise consider entering the profession. This is especially true when one considers other cost-raising factors that disproportionately affect women, such as the need for child care during the schooling period. A shift to apprenticeship learning would not only allow new PSWs to “earn while they learn,” reducing educational barriers to entry, but also prepare them for the reality of modern LTC work.
Moving personal support work in the direction of a skilled trade could strengthen the dignity and political voice of the profession without raising barriers to entry (and thus also worsening labour-supply challenges). As we have noted, the possession of a trade certificate is linked to better financial outcomes, especially for women. As is the case in other crafts and trades, policy-makers should rely on unions and employer associations to develop an apprenticeship program based on their well-developed understanding of the knowledge and skills PSWs need to succeed in a LTC career.
The NDP’s proposed training fund would also be a positive step toward ensuring that staff are equipped to meet the needs of increasingly high-acuity residents. We encourage policy-makers to rely on the diverse group of employer associations and unions working in this sector to develop and administer this fund. These organizations are most closely attuned to the dynamic front lines of the LTC sector—they know best what the needs of their employees and members are, and how to meet them.
This model, already active in other industries (such as construction), would be a solid step toward developing a well-trained workforce. Again, emphasis should be placed on ensuring that there are plural providers to prevent the concentration of patron-client relationships with the state.
Short-Sighted and Counterproductive: Profit is not the Primary Cause of LTC's Pandemic Problems.
The NDP’s plan, however, is wrong to claim that eliminating for-profit ownership is the solution to Ontario’s LTC problems. It is unfair and misleading to suggest that PSWs “are badly overworked and underpaid” because “for-profit corporations keep staffing levels dangerously low, and use part-time and temp workers instead of full-time staff.” As we have outlined in a previous paper, the poor wages and working conditions of PSWs are not unique to homes owned by for-profit companies. There are several structural challenges to PSW funding. These include:
- a single source of revenue constrained by rising health and other government costs,
- employers who are unable to exercise any real agency due to the de facto centralized structure of bargaining and funding arrangements, and
- the educational barriers discussed above
These structural problems have contributed to a staffing crisis across the entire LTC sector, including not-for-profit and public homes.
Blaming “greedy profit-driven corporations” and other governments’ “CEO and lobbyist friends” for LTC’s problems is easy and makes for a politically popular sound bite, but banning for-profit providers from LTC is a simplistic, reductive response that fails to solve the underlying, structural issues with LTC and its labour-market challenges.
In a healthy market, diversity of options and competition between them would hold all players accountable. Different homes (including for-profit, non-profit, and public) would compete to attract residents by offering better care and to attract skilled workers by offering better compensation. These positive forces have been stifled by a bloated wait-list that deprives seniors and their families of real choice in where to receive care and by structural distortions that have prevented the LTC labour market from responding as it should to a severe labour shortage in a competitive environment: with higher wages.
The NDP’s plan includes several strong proposals that are far better positioned to get at the root of these underlying problems—such as investing in wait-list reduction, including by making it easier for non-profit homes to start, and addressing the staffing crisis—than its plan to eliminate for-profit homes.
Our intention is not to ignore or downplay the issues associated with for-profit LTC facilities. We are familiar with the research that has found worse outcomes for for-profit compared to public or non-profit facilities. Yet forcing all for-profit providers out of the sector is not a feasible way to address these issues and would be counterproductive to the goal of providing Ontarians with care.
As the NDP’s plan points out, for-profit facilities make up nearly three in five of Ontario’s LTC homes; they operate over 42,000 beds. The NDP promises to stop issuing new licenses to for-profit care providers and to ensure “municipalities, not-for-profits and other public sector and community health organizations” take over all services delivered by for-profit providers, within eight years. It also states that the NDP would create up to 50,000 new spaces to eliminate the wait-list over the same period. In other words, the NDP expects non-profits and municipalities to nearly triple their existing LTC capacity—from 36,000 beds to 92,000 beds—in less than a decade. The question arises: How?
Even if Ontario had unlimited funding for an overhaul of this magnitude, throwing money at these groups would not be enough to develop thriving homes from scratch. The NDP’s plan recognizes that preserving seniors’ communities is critical. And one of the major strengths of non-profit and charitable homes is the connections many of them maintain with their local communities. Cultivating a sustainable base of social, financial, and volunteer support is an organic process that takes time, patience, and the right people; government is severely limited in its ability to create an engaged community of care.
There are better, more realistic ways to fix the problems the NDP has linked to for-profit ownership. While evidence suggests that for-profit homes experienced larger outbreaks and had more resident deaths from the COVID-19 virus compared to municipal and non-profit homes, ownership status was not connected to the risk of an outbreak. A significant contributor to the higher death rate in for-profit homes was outdated design—for-profit facilities are more likely to be built according to older design standards that hinder infection containment. Renovating these facilities rather than buying out for-profit LTC providers would increase resident safety at much lower cost, freeing up funds for other needed improvements to the system, such as increased staff capacity and building new beds in family-style homes. LTC stakeholders and researchers have raised important concerns about for-profit providers’ incentive to increase profits by decreasing expenses and the effect of this incentive on staffing levels. Policy-makers should explore funding reforms that ensure adequate staffing levels for all homes and make profit an incentive to encourage excellence, innovation, and improved quality of care.
Caution: Paperwork Takes Away from Care. Let's Improve, Not Unduly Expand, Reporting.
Another noteworthy aspect of the plan is its promise to strengthen protections for seniors through a designated advocate and a more rigorous inspection regime. The NDP’s commitment to protecting seniors and their caretakers is admirable. The devastating impact of COVID-19 on LTC homes is a tragedy that should never have been allowed to occur and must never be allowed to happen again. Making the inspection process more onerous and punitive, however, is unlikely to provide the protection the NDP seeks. This is not to downplay the importance of regular inspections—accountability is essential. Yet reports from stakeholders suggest that ensuring quality of care requires reforming rather than intensifying the current inspection system.
Ontario’s LTC homes are already subject to an average of forty-three days of inspection per year. There is a real risk that toughening this regime even further will worsen rather than improve quality of care. LTC workers have reported a punitive system in which inspectors scrutinize paperwork for errors rather than observe quality of care. Over-regulation has shifted workers’ focus from providing excellent care to documenting compliance. This not only undermines the very quality these regulations were intended to preserve, it demoralizes staff who are forced to prioritize paperwork over residents’ needs. All inspections (including and especially incident or complaint inspections) need to be redesigned away from the current emphasis on compliance and documentation, and focus on care outcomes, resident/staff experience, systemic safeguards, and practical solutions to real problems.
In fact, the NDP plan makes no mention of the paperwork burden that many PSWs have identified as a significant barrier to effective care. Documentation is an important part of care, but every minute that a PSW is forced to spend on redundant or unnecessary paperwork takes away from direct, hands-on resident care. When residents receive less hands-on care, their health and quality of life suffers—a deeply distressing cycle for the many workers who entered LTC to help residents. Partial and inconsistent access to technology is a common cause of documentation redundancy: if there aren’t enough tablets to go around, some PSWs have to do mandatory charting using paper at the bedside, leaving the information to be re-entered into the digital system later. One way to address this in the short term and introduce greater accountability on expanding resident needs would be to pay for charting/documentation costs out of the housing envelope rather than the care envelope. This change would reduce the amount of surplus funds that could be kept by for-profit homes and create incentives for these providers to make documentation procedures more efficient.
Conclusion: The NDP's Proposal is a Serious Start to Reforming Long-Term Care. Let's Act Together.
The NDP’s LTC plan proposes several good steps toward addressing some of these challenges: transitioning to a community, rather than institutional, approach to LTC; improving staffing levels and compensation; and reducing educational barriers for prospective PSWs. These proposals are excellent ideas and would go a long way toward building a better LTC system for our province.
The NDP’s plan, however, focuses disproportionately on for-profit ownership as the source of LTC’s failures. The NDP is not alone in criticizing for-profit homes and demanding they be eliminated from LTC. While we agree that Ontario’s LTC sector is in desperate need of bold action and longterm reforms, we do not believe abolishing for-profit ownership would fix LTC’s problems.
We urge policy-makers of all parties to attend to the structural challenges that have brought LTC and its workforce to the breaking point, and to work with LTC stakeholders to develop lasting solutions. The system does not need tweaks—it needs strong action of the order of boldness found in the NDP’s plan. We hope this proposal sparks an initiative by all parties to bring ambitious reforms to LTC in Ontario.