“Extreme Neglect”, “Heart Breaking”, “Gut Wrenching”, “Nauseating”: these responses to the LTC Military Report are, sadly, nothing new to caregivers, families, and seniors’ advocacy groups. We have all seen, heard of, or experienced the passing of a loved one in a seniors’ care home. We are not surprised that nearly 82% of Canada’s COVID-19 deaths have been in long-term care homes, but the deaths in these homes are merely the tip of the iceberg.

When the provincial government wants to reduce its expenditures, it looks at cutting funding to the Ontario health care system, the largest budget envelope. Ageism then allows, even encourages, us to prioritize younger patients with acute conditions over older folk with increasingly complex chronic conditions.

Instead of wringing our hands in outrage (again), let’s look at alternatives. Better quality and improvements to home and community care can keep seniors safely in their homes and out of more costly institutions, such as nursing homes and hospitals.

In Ontario, care for most seniors is delivered at home and with community-based support. Let’s not be consumed by the flashier statistics (LTC homes) and forget the situation in home and community care. This sector is also suffering, if less dramatically, from some of the same problems as LTC homes – shortages of qualified staff, who endure precarious employment, as well as lack of personal protective equipment and clear infection control guidelines – guidelines much needed given the less than perfect conditions in some homes.

Ontario’s senior citizens need decisive action. We already have more than enough information to correct this sad situation and re-orient long-term care.

What exactly are we waiting for?

The Ford government is pursuing passage of legislation that will significantly affect the home and community care services available to all Ontarians. Care Watch applaudes the government’s goal of modernizing home and community care, but continues to have serious concerns about the proposed legislative changes.  Our submission to the Standing Committee on Social Policy calls for clarification of and changes to Bill 175.

The COVID-19 pandemic has highlighted what is very wrong with the way we care for Canada’s senior citizens.
Care Watch has long advocated that the Canada Health Act’s five legislated principles (public administration, comprehensiveness, universality, portability, and accessibility) should apply to long-term care services, whether those services are in institutions, at home, or in the community. We have also called for national senior care standards that would reflect those principles. We are not the only ones calling for these standards. This call is also trumpeted by organizations and unions supporting pandemic front line workers. Included are the Ontario Health Coalition, SEIU, ONA, and Unfor. Now, the Globe & Mail’s opinion editor Gary Mason (May 8, 2020) has gone even further by advocating that seniors’ care be formally included in the Canada Health Act.

Prime Minister Trudeau (Toronto Star, May 8, 2020) says the post-pandemic reviews will consider bringing long-term care under the Canada Health Act’s umbrella. However, the premiers of some provinces (such as Ontario and Quebec, which, ironically, are most affected by the pandemic) are already lining up against the potential of applying any national standards. They argue that it is unnecessary and that the federal government should simply give them more funding to address the issues.

We believe provinces should receive more funding only if that funding is tied to enforceable national standards. COVID-19 has shown us that neglect of standards leads to neglect of care. We assert that long-term care services – in the home and community or in facilities – are necessary components of our broader health care system and must be treated as such.
Post-pandemic, we can expect many of our systems to be restructured. Structures change and evolve, but values and principles remain constant. National frameworks such as the Canada Health Act provide a foundation and guidance for consistent and coordinated provincial/territorial action. We continue to learn from the pandemic experience, but we have already learned that long-term care needs to be guided by the Canada Health Act.

When we talk about our health care system – especially when the system is being restructured – discussion turns to the balance between public services (provided by government) and private services (provided by entities other than government). It’s a dynamic balance, which shifts constantly and depends on each government’s policies and programmes.

It is important to understand that balance, and where public and private interests and activities meet in our health system.

Read our latest backgrounder examining privatization in Ontario’s health care

Care Watch prepared a Backgrounder on Applying Canada Health Act Principles to Home Care and Community Support Services.  In a series of posts, we have been presenting sections of this document (which you can find here).  Today, we begin to look at the principles: Public Administration; Comprehensiveness; Universality; Portability; and Accessibility.

Public Administration (Section 8)

• Public health insurance must be administered by a public authority on a non-profit basis, accountable to the province or territory, and with records and accounts subject to audits.

Analysis

Medicare is publicly funded via general and specific taxes administered by each provincial/territorial government and its designated crown agencies, which are publicly accountable for expenditures and performance. Each government determines the extent and amount of services covered. To foster Canada-wide equity, programming, and standards, the federal government also gives some provinces equalization funds.

In Ontario, the Ontario Health Insurance Plan Act (OHIP) and associated regulations outline insured services. The Ontario Medical Association negotiates physician fees and the Ontario Hospital Association negotiates hospital fees; the resulting fees, reflected in OHIP’s Schedule of Benefits and Fees, are deemed regulations.

In 2006, Ontario’s government delegated health service planning and funding to 14 regional health authorities (local health integration networks, or LHINs), which allocated funds and managed provider contracts within geographic regions. In addition to planning and funding institutional services (except for physician services), LHINs were responsible for funding HCC through Community Care Access Centres (CCACs). However, a 2015 Auditor General of Ontario report identified some 1,500 different service agreements with HCC delivery agencies, with a multitude of financial arrangements for the same or similar services. Understandably, the report questioned how, and how effectively, public resources were being used.

Under Ontario’s restructured health system and Bill 175, Ontario Health will assume responsibility for overall system planning and funding home and community care services. Coordination and delivery of these services will become the responsibility of interim service providers called Home and Community Support Services (formerly LHINs) for a transitional period and, eventually, the sole purview of local Ontario Health Teams.

Funding for home and community care will be allocated to and through the health teams. It isn’t yet clear how these health teams will be accountable for their use of public funds or for the performance of services they choose to deliver, and especially how they will plan, allocate, protect, or sustain funding for home care and community support services. It is also not clear how they will negotiate fees and payments.

Accountability for and public reporting of system expenditures currently rest with Ontario’s government, and expenditures are subject to audit by the provincial auditor general. Crown agencies, such as Ontario Health, which deliver and manage insured services, are similarly accountable for their use of public funds. Other providers, such as health teams, health service organizations, and/or contracted service providers, however, have limited public accountability. For example, for-profit home care and community care providers receiving public funding don’t have to provide detailed public financial or service performance reports. The auditor general has had limited authority. The principle of public administration and accountability could be at risk, leaving the question of who is minding the store.

On February 25, 2020, Ontario’s Minster of Health tabled Bill 175 – Connecting People to Home and Community Care Act, 2020, which significantly changes home and community care. There has been little, if any, public consultation. Care Watch is concerned that when government’s regular business resumes, the Bill could be pushed through quickly without clear information about how services will actually be delivered. We developed a briefing note which summarizes our comments, concerns, and questions.

Read the briefing note and other materials on home and community care here.

(We will resume our analysis of the Canada Health Act principles in the next post – stay tuned!)