New long-term care standards will fall flat without money or enforcement, experts warn

The federal government is spending $3 billion over five years to establish new standards to improve long-term care in Canada. Advocates say the money alone is not enough — that they want measures to ensure new standards actually lead to better care for seniors.

Expectations are high for the new standards, now being developed by the Health Standards Organization (HSO) and the Canadian Standards Association (CSA). The work will take at least another 20 months but those involved say they hope new standards can help prevent the dire conditions that contributed to high pandemic death rates in the long-term care sector.

In the first wave of the pandemic, long-term care facilities saw 80 per cent of Canada's total COVID-19 deaths. Outside of Quebec and Nova Scotia, deaths in long-term care actually increased in the second wave.

But experts warn that new standards alone won't solve the many problems in the sector exposed by the pandemic. They say they fear that, after decades of government indifference to long-term care, public pressure to fix those problems might fade as the pandemic wanes.

"I do not want these standards to sit on a shelf and not be used," said Alex Mihailidis, technical subcommittee chair for the CSA.

"If we can take anything positive out of this pandemic and everything we've seen happen … I think we are at the tipping point and that is going to really drive the political will and social will forward and ensure that these standards are really taken seriously."

What would new standards look like?

Experts say the long-term care sector needs to improve both the delivery of care and the operation of its facilities. That extends to everything from the number of hours of direct personal care residents should expect to staff-resident ratios and infection prevention and control practices.

It also includes ventilation systems, plumbing, medical gas systems and facilities' use of technology. All of those things could depend on possible new infrastructure standards, which could dictate how new long-term care homes should be built, how many residents can be put in a single room and how common and isolation areas should be constructed.

The HSO and CSA also will have to work out how infrastructure standards would apply to existing buildings.

"We're pushing to basically say with everything that we've learned so far, with everything we're learning about the state of long-term care in Canada, how do we actually make these new standards pandemic-proof?" said Dr. Samir Sinha, the director of geriatrics at Sinai Health and the University Health Network in Toronto. He's heading up the technical committee for the HSO.

The HSO already has standards for long-term care homes; the pandemic proved they're clearly insufficient. Across Canada, almost 70 per cent of long term care homes are accredited based on either those HSO standards or a U.S.-based equivalent.

In Quebec, 100 per cent of homes require accreditation. But Quebec's long-term care homes were among those hardest-hit by the pandemic.

Dr. Sinha acknowledges that 20 months is a long time to wait for new standards, but the work takes time.

"This is actually how you end up developing good quality standards. Or do you want to just be politically expedient and get more of the same of what?" he said.

"Because whatever we've been doing so far, frankly, hasn't worked well. Now that everybody's attention is on this, I'm determined to make sure that we do this right."

Public input

Normally, in standards development processes, technical committees made up of stakeholders and experts work on draft standards that are then presented to the public for input and review toward the end of the process.

But the death toll in the long-term care sector during the pandemic has generated a massive amount of public interest in this process — especially among those who've lost loved ones in long-term care.

The HSO and CSA are expected to take into account the results of public surveys on long-term care standards and are holding town halls to solicit input starting this summer. And the HSO technical committee was assembled in part through a public application process.

Will new standards make a difference?

The answer to that question depends on what the provinces do. Provinces — which are primarily responsible for long-term care — will be called on to spend the money needed to meet those standards and to fill massive staffing shortages.

Experts also say the effect of new standards will depend a lot on whether they're mandatory, and whether those facilities caught violating them can expect penalties.

"Unless they're mandatory, then they are a wish list of what we think is important and that's not going to really make substantive change," said Laura Tamblyn Watts, CEO of CanAge — a national seniors advocacy organization — and an adjunct professor at the University of Toronto.

"So it's important that those standards have some type of force of law and that breaking them [has] some type of profound penalty against them."

Tamblyn-Watts said long-term care homes almost never lose their licenses to operate for violating standards and the fines they face are "almost laughable."

Technically, the federal government could create its own legislation and regulations to make the standards mandatory. Experts say that's unlikely.

Still, in a March interview with CBC, Health Minister Patty Hajdu argued enforcement is key.

"It's not just a question, for me, of having standards. It's about also a commitment and a path forward to enforcing those standards, or to upholding those standards," she said.

"Because, of course, some provinces and territories did have standards and it didn't necessarily lessen the tragedy in those provinces and territories. So it's about figuring out what the standards need to be. And then the separate process is how you ensure that those standards are applied consistently, so folks that are dependent on care are indeed safe in those places."

How much would it cost?

The Standards Council of Canada says it plans to contribute up to $340,000 to fund the work on long-term care standards.

The real price tag, of course, is what ultimately gets spent by federal and provincial governments to ensure the standards mean something. Critics say the $3 billion over five years Ottawa is offering the provinces is simply not enough.

"That's about six or seven dollars per resident per day," said Terry Lake, CEO of the B.C. Care Providers Association, which represents 400 long-term care and assisted living homes. Lake is a former provincial health minister.

"You have to have the provinces on board to make them mandatory because health care is provincial jurisdiction. There are carrots and sticks and the carrot, of course, from the federal government is funding. I think some provinces may be reluctant to have a standard that's enforced without more funding going in to incentivize those standards."

Already, some provincial governments have bristled at the idea of taking any direction from Ottawa, money or no money.

"I think those premiers are reading their populations wrong. These jurisdictions have had extremely bad outcomes in long-term care and much of it was preventable," said Tamblyn-Watts. "The pushback is out of step with how furious and distraught the voters are about it."

But a number of recent provincial budgets that committed money to building new homes or increasing staffing in existing ones have been criticized for not setting aside anything close to what is required — even at a time of intense public pressure for change.

Advocates say they fear that's not a sign the political will is there to ensure the thousands of people who died in long-term care homes during the pandemic did not do so entirely in vain.