“They cut hospital beds and lay off staff without having community health care services ready…”
“When the elderly… decide that facility-based care is the best option, they can’t get it…”
By David South
Seniors should keep a close eye on the Ontario government’s proposed long-term care reforms. According to critics, the plan has more than a few bugs.
The term long-term care encompasses an often confusing web of services, from home-provided community services like meals on wheels to institutional care including homes for the aged, seniors’ apartments and chronic care hospitals.
Like other provincial governments, the Rae government is trying to rein in escalating health care costs – and long-term care services aren’t immune. They hope that emphasizing prevention and healthy lifestyles, plus providing more services in the home and community, will reduce reliance and expensive health care services like high-cost drugs, surgery and high-tech equipment. According to health minister Frances Lankin, this will preserve medicare in the age of fiscal restraint.
The government has outlined seven goals for its long-term care reforms: prepare for the coming surge in the over-65 population; cater services to better reflect the cultural, racial and linguistic make-up of Ontario; eliminate confusion over what services are available; involve the community in planning so that services reflect community needs; lessen reliance on institutions; provide support to family caregivers; tighten regulations governing government-run and private facilities; and improve working conditions for the largely female caregiving workforce.
But many people are wary of the proposed reforms and worry that if they aren’t managed properly, some seniors will fall through the cracks.
A report released in July by the Senior Citizens’ Consumer Alliance for Long-Term Care Reform blasts the government for being simplistic in its plans. The report compares the present reforms to the failed attempt in the 1970s to move psychiatric care out of the institutions and into communities by closing 1,000 beds. The tragic result in that case was homelessness for many psychiatric patients who found community services unable to help, or, more often than not, non-existent. The Alliance fears seniors – the biggest users of health services – could fall victim to reforms in a similar way.
Emily Phillips, president of the Registered Nurses’ Association of Ontario, is blunt: “The NDP’s plans sound good on paper, but they can’t give a budget or direct plan on how they hope to carry out reforms. They are going about things backwards. They cut hospital beds and lay off staff without having community health care services ready.”
The Ontario Association of Non-Profit Homes and Services for Seniors (OANHSS) – which operates charitable and municipal homes for the aged, non-profit seniors’ apartments. chronic care hospitals and community services serving over 100,000 seniors – says 4,300 seniors are on waiting lists for their member facilities right now, and things won’t improve if the government continues to reduce the number of long-term care beds.
But Lankin insists that beds are available in homes and hospitals and it is funding formulas that prevent them from being filled.
To help carry out its reforms, the NDP will reallocate $647 million by 1996-97. In bureaucratese, this funding is said to be “back-end loaded”, or mostly spent close to 1996-97.
The problem with this, according to the Alliance, is that the government has already embarked on a radical “downsizing” of hospitals, closing beds and laying off health care workers. Lankin claims the worst case scenario for layoffs this year won’t exceed 2,000, but the Ontario Hospital Association claims 14,000 jobs are in jeopardy. Because of this, the Alliance wants money to be spent earlier to avoid gaps in services.
Phillips believes it will be hard to pin down the extent of job losses. “For every full-time job cut many part-time and relief positions go with it,” she says.
Dr. Rosanna Pellizzari, a member of the Medical Reform Group and chair of the Ontario Association of Health Centres, wants better community accountability for hospitals before they lay off staff and cut services. “Sometimes it makes sense to bring people to hospitals,” she says. “Planning must be at the community level, open and democractic. Health care workers, who are mostly women, should not be scapegoated for financial problems. Doctors and management should go first. Physicians experience very little unemployment.”
Many nursing and charitable homes for the aged are facing financial crisis. According to OANHSS, six charitable homes for the aged have closed since 1987 due to deficits. In 30 homes, the total annual deficit has increased 125 per cent since 1987. The Ministry of Health recently allocated special funds of $8.1 million to ensure these facilities survive until January, when a new, needs-based funding formula will be introduced. It is intended to better match the actual care requirements of the 59,000 consumers living in long-term care facilities.
Michael Klejman, executive director of OANHSS, agrees with helping seniors to stay in their homes. “But when the elderly and their care-givers in Ontario decide that facility-based care is the best option, they simply can’t get it,” he notes. “We know from experience that many of them remain in acute care hospital beds with a cost to the province of about four times what it would cost them to fund a long-term care bed. And many, unfortunately, remain in their own flats or apartments at considerable risk to themselves, isolated and dependent on a patchwork of services.”
Beatrix Robinow, who worked on the Alliance’s report, was not impressed with the government’s initial plans, especially the proposed creation of 40 service coordination agencies whose mandate would be to control the delivery of home care services to seniors. Robinow thinks this would add to the confusion and just be another layer of bureaucracy. Many people who appeared at the Alliance’s public hearings expressed confusion over how the long-term care system worked.
Robinow says that the government could save money by trimming the bureaucracy and using present organizations like the little-known District Health Councils.
“District Health Councils have nothing to do with social services,” says Robinow. “But we want them to be expanded to include long-term care and general supervision of community services. We are waiting to hear if they are interested. I would urge the government to make sure that services are in place before pushing people out of institutions.”
The health minister is cautious about the government’s next steps. “The Alliance’s report has been very helpful,” she says. “We are in the process of developing options. Two other ministers are involved and we also need to take this through Cabinet.
“Ontario is much larger and more complex (than other provinces). The range of services is more developed. We also have a mess in jurisdictions between municipalities and the province. And in Ontario there isn’t a concensus that this is the way to go.
“We have been doing a lot of rationalization and streamlining for longer than other provinces. Most thinking people looking at the situation agree that doing nothing would hurt the system. It is not sustainable at present. You hear a lot of things about user fees. That would be the slippery slope for medicare. That would make people think they could buy better services.”
Ironically, user fees were recently endorsed by the Canadian Medical Association, suggesting the minister will have a fight on her hands with angry doctors.
Amidst all the confusion, Dr. Perry Kendall was appointed on Aug. 24 as the provincial government’s special advisor on long-term care and population health. This veteran of both the City of Toronto as Medical Officer of Health – and the groundbreaking Victoria Health Project in British Columbia (often seen as the model for community services to seniors) seems well qualified. “One problem in the past has been the creation of smaller and smaller organizations every time somebody felt the system was not responsive to their needs,” he says. “This created organizational chaos. The challenge now is to get all the organizations back together to share their expertise.”
Lankin says she hopes to have a conference on the reforms in the fall.