Can this pandemic be the crisis that finally forces us to fix long-term care?
The death toll in long-term care should horrify us all — enough to finally fix a badly broken system
A crisis can reveal the strengths of institutions, societies, citizens and leaders. It can also expose weaknesses.
"Right now, we're seeing terrible tragedies in long-term care facilities across the country," Justin Trudeau said Thursday. "This is unacceptable."
The prime minister's comments on the rising death toll inside Canada's nursing homes and seniors centres were his most negative since this crisis began, and marked a departure from the reassuring tone he's largely stuck to over the past six weeks.
"If you're angry, frustrated, scared, you're right to feel this way. We can do better. We need to do better. Because we are failing our parents, our grandparents, our elders — the greatest generation who built this country," Trudeau continued. "Going forward in the weeks and months to come, we will all have to ask tough questions about how it came to this."
In terms of public policy, COVID-19 will leave behind a number of success stories. Thousands of public servants have worked to implement and deliver billions of dollars in relief. Federal and provincial leaders have collaborated across jurisdictions and party lines. The Canadian health care system has, so far, held up much better than the system in the United States.
A 'broken' system
But this pandemic also showed us where we're failing as a country — in particular, how we care for the oldest and most vulnerable among us.
"I recognize the system is broken and we are going to fix the system," Ontario Premier Doug Ford said this week.
Other issues have come to the fore over the last month and a half: the importance of child care, the need for better and faster health and economic data, the limited fiscal capacity of some provinces, the fragility of international supply lines. But the most glaring problem to emerge is the one in our long-term care centres.
In Ontario, 573 residents of long-term care facilities have died — that's 75 per cent of the province's death toll. In Quebec, 1,045 residents have died — nearly 80 per cent of the provincial total.
"I think the tragedy of COVID-19 is that it's exposed a number of the weaknesses that have been long-standing," said Dr. Samir Sinha, director of geriatrics at Mount Sinai hospital and the University Health Network Hospitals in Toronto.
Soldiers in our seniors' homes
Governments in Canada have responded to the immediate crisis with a number of short-term measures. The government of British Columbia took over staffing for some nursing homes around Vancouver — in part to track workers who may be employed at more than one facility and can become vectors for the virus as a result.
Caregivers are often not well paid, Sinha says, which can lead them to take jobs at more than one centre. Both B.C. and Quebec have increased pay for front-line workers, a measure the federal government has said it is willing to support. Both Quebec and Ontario have asked the federal government to task the Canadian military to help with staffing shortages.
"But this is not a long-term solution," Trudeau said Thursday. "In Canada, we shouldn't have soldiers taking care of seniors."
"We've never funded the system with the same consideration that we fund the hospital sector," Dr. Sinha said.
Dr. Sinha notes that COVID-19 is a new and fast-moving disease — a significant challenge under any circumstances — and containment measures have been implemented gradually.
A road map for reform
Figuring out how so many residents of long-term care facilities lost their lives to the pandemic will involve examining many possible factors. But last fall, Dr. Sinha co-authored a report that identified a number of issues with the way care is delivered in this country — issues that now seem like ripe targets for reform.
Long-term care was not enshrined in the Canada Health Act, the federal legislation that sets out the parameters of public medicare. Existing long-term care services are a patchwork of public and private options.
Demands on providers are increasing, but front-line workers have been, in the words of that report, "underappreciated, overworked and underpaid." Unpaid caregivers — family members and friends who take care of loved ones — are struggling with their own burdens.
Long-term care on the cheap
As a share of GDP, Canada's annual public spending on long-term care — approximately $24 billion — is below the average of 15 other OECD countries that report long-term care expenditures. Countries such as the Netherlands, Sweden, Denmark and Norway spend twice as much.
Canada also devotes a much higher percentage of its spending to facilities like nursing homes than it does to community-based care: 87 per cent versus 13 per cent. In Denmark, the ratio is almost the reverse: 64 per cent of public spending there goes to home care, while 36 per cent goes to designated facilities.
Health care delivery is a provincial responsibility, but the federal government plays a significant role in funding, assisting and overseeing those services.
A role for Ottawa
A report by the Canadian Institute for Health Information in 2017 estimated that 22 per cent of seniors in nursing homes might be able to live at home — and recent federal interventions have been aimed at making that easier.
In 2015, the Conservative government introduced a tax credit to provide as much as $1,500 toward renovations to make a home more accessible for seniors. In 2017, the Liberal government introduced a caregiver benefit through employment insurance and committed $6 billion over ten years to help provinces improve home-care services.
But overall health spending remains a point of friction between the federal and provincial governments. Between 2004 and 2016, the federal transfer for health care increased at an annual rate of 6 per cent. Since 2017, the annual increase has been tied to GDP, with a minimum rate of 3 per cent.
In 2018-2019, the Canada Health Transfer grew by 3.9 per cent. Last fall, the provinces renewed their demand that the annual increase be set at 5.2 per cent.
Crisis and opportunity
That debate likely will play a big part in any discussions about the future of long-term care in Canada. But Dr. Sinha said there's an opportunity here for the federal government to provide leadership and direction.
Health crises in Canada have led to changes in public policy before. The federal Department of Health was created in the aftermath of the Spanish flu epidemic in 1919. This week, federal ministers at least seemed willing to acknowledge a need to do something.
"I think there should be a long term national project to examine long term care homes and how we can better support [them] at every level of government, to make sure people who are living there are protected and can live their lives in dignity and safety," Health Minister Patty Hajdu said Thursday.
In the wake of so much death, a renewed focus on long-term care — and public demands for action — might force politicians to stick to such commitments.
"We've had [more than] a thousand older people die," Dr. Sinha said. "And if that's not a call to action, to fundamentally reform the entire way our country provides long-term care, then I don't know what is."
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