CUPE Health Care

The main reason for these counter-intuitive reactions to increased demand is the way hospitals are funded. As in most of the rest of Canada, hospitals in Quebec currently receive their funding in the form of global budgets based essentially on the amounts they spent in the past. This kind of lump-sum funding leaves hospitals with a tough choice: Limit admissions or go over budget. There is no incentive for hospital administrators to innovate and become more efficient, since an innovation that reduced expenditures would lead to an equivalent decrease in the hospital's next budget. On the other hand, an innovation allowing wait times to be reduced and more patients to be treated entails increased pressure on the fixed budget.

Almost all other industrialized OECD countries fund their hospitals to a large extent based on services rendered. With such activitybased funding, hospitals receive a fixed payment for each medical procedure, adjusted to take into account a series of factors like geographic location and the severity of cases. The more patients a hospital treats, the more funding it receives. Generally speaking, in countries where activity-based funding is widely used, there is more competition between medical facilities and quicker access to care. Health Minister Gaétan Barrette has said that the Quebec government wants to adopt activity-based funding for medical facilities in the health network. This would make a lot more sense than demanding that MUHC doctors refer oncology and ER patients to other hospitals, as the Health Ministry is currently doing.

But getting rid of Quebec's anachronistic funding of its hospitals through global budgets, while a step in the right direction, should be accompanied by other, complementary measures such as mandatory quality reporting for hospitals. Giving patients and referring doctors access to the information they need in order to determine the best hospital for each case would allow for some healthy competition, leading to quality improvements throughout the system, as has happened in Germany in recent years.

If Brian Day's constitutional challenge now being considered by the British Columbia Supreme Court is successful, two other European measures could also come to Canada: allowing a market for private insurance to develop, and allowing doctors to practise both in the public sector and in the private sector.

International experience confirms that the presence of a mixed health care system is not incompatible with health care services that are accessible to all. Indeed, such measures could improve access to health care by encouraging entrepreneurship without undermining the principles of equality and universality that Canadians hold dear. Jasmin Guénette is vice-president of the Montreal Economic Institute.

Last week, the Parkland Institute - which is based out of the University of Alberta - released its report Losing Ground: Alberta's Elder Care Crisis. It was an update of another Parkland report from 2013. The report states that as of March 31, 2016, there were 14,768 longterm (LTC) beds in Alberta and 9,936 designated supportive living (DSL) beds, as well as 243 palliative care or hospice beds.

The number of LTC beds in Alberta has been relatively stagnant - Alberta only has 377 more LTC beds than it did in 2010, an increase of only 2.6 per cent. The number of DLS beds, on the other hand, has increased by 4,770 or 92.3 per cent. As well, the number of continuing care beds classified as DLC as opposed to long-term care beds grew from 26 per cent in 2010 to 40 per cent in 2016.

That means nearly half of the continuing care beds available in the province for elderly Albertans do not have a registered nurse on-site and are not subject to minimum staffing requirements. "Losing Ground" also examines who is operating the LTC beds in the province. About 21 per cent are operated by Alberta Health Services (AHS) or a regional health authority. Another 10,808 were run by for-profit corporations and 8,881 were run by non-profits. In the last seven years, Alberta has lost 333 beds in public facilities while private, for-profit facilities have added 3,255 beds.

The issue is that publicly-run LTC facilities generally provide more health care to residents than privately-run or non-profit facilities. On average between 2011 and 2013, registered nurses, licensed practical nurses and health care aids in public facilities provided four hours of direct health care to residents compared to three and 3.1 hours per day in non-profit and private facilities respectively. The report stresses that all facilities are required to provide 4.1 hours of care per day to residents, which means they are all falling short due to a lack of staff.

The report also notes that the NDP government has fallen far short of its election commitment to open 2,000 new long-term care beds by the end of 2019, including 500 new beds in 2015. The growth in the older population, coupled with a stagnant number of new LTC beds and move towards private care, means the availability of beds for Albertans over the age of 85 has nearly been halved since 2001. "This drop has greatly reduced the province's ability to meet the care needs of its most frail seniors," said report author David Campanella, in a release.

Minister's response In an e-mail, Minister of Sarah Hoffman said they know there is a huge demand for longterm care and dementia beds that stems from "years of neglect" on the need for affordable spaces for seniors under the previous government. "As a result, we are building spaces and putting in the beds Albertans need as we committed to do in the election and we are doing it collaboratively with communities and community partners." Hoffman said that last year, the province did a thorough review of all proposed Affordable Supportive Living Initiative (ASLI) projects, and implemented important changes to proposed projects to address the needs of Albertans.

Every new approved ASLI project has since opened with higher numbers of dementia and long-term care beds than originally planned, she said. "With ASLI now ended, we are developing a new capital program for long-term care with criteria to ensure the right level of care and the right methods of delivery are expanded," said Hoffman. She noted they have $365 million earmarked for senior care in the current budget and that will improve access for families across Alberta. Following the report's release, the Canadian Union of Public Employees (CUPE) issued a statement that it is disappointed by the lack of progress being made reforming the province's system of senior care.

CUPE Alberta president Marle Roberts said the union, which represents 2,600 long-term care workers throughout the province, has repeatedly asked the current and previous Alberta governments to shift its focus to publicly-delivered services. "This study confirms what others have indicated before - caregivers in public facilities have more times for patients and deliver better outcomes," said Roberts.

We are disappointed that the number of private beds continue to increase, while the number of public beds has dropped ... We are letting patients down by not offering them the care they need," she added.

A report from the Parkland institute claims there has been a trend away from publicly- run long-term care beds, such as those at the Westlock Continuing Care Centre (seen above). The number of long-term care beds offered by private organizations or non-profit organizations, on the other hand, is on the rise.

Deliver pharmacare

Fix Employment Insurance.

It should, for instance, reform the labour code so all workers get a minimum level of paid sick leave.

After decorating Halloween cookies together, Han brings his own masterpiece, smothered in smarties and sprinkles, to Clark and encourages her to try it. Few words are exchanged, but smiles and giggles are constant at the intergenerational program at Youville Residence, a long-term care facility for seniors in Vancouver. Han Jr. is among a half dozen children visiting this day from the Montessori Children's Community - a daycare located on the same site as Youville, at 33rd and Heather.

Montessori Children's Community administrator Kristina Yang said it's a win-win situation. "Even if there is not a lot of communication with words you can see the beautiful smiles on everyone's face. Many of the children come to know a lot of the seniors and when they pass by our window they'll be excited waving and saying 'Hi ,'" Yang said.

Youville occupational therapist Sheralyn Manning said the children's visits are a big part of the seniors'day. Besides planned events, such as doing crafts together, every so often the children will visit when the weather is bad and they are not able to play outdoors. Manning pointed out the friendship between Clark and Han has been particularly touching to watch and Clark has a recent craft project Han gave her prominently displayed in her room. When most people think of nursing homes the image that comes to mind is a stand-alone building offering residential care only for the aged.

It's a place seldom visited unless you are a family member, friend or volunteer. But these days more homes are trying to build bridges to the wider community. Of B. C.'s 460 government and private nursing homes, only a handful have daycares or doctor's offices on site, said Daniel Fontaine, CEO of the B. C. Care Providers Association, which represents 60 per cent of the privately-operated homes. But none are attached to a facility that offers a large variety of community services. One of the best Canadian examples of a nursing home that achieves just that, said Fontaine, is Niverville Heritage Centre, near Winnipeg. It is home to 116 seniors but is also a gathering place for major community events.

Creating community connections is key as Providence Health begins its planning stage to replace some of its older nursing homes in Vancouver, said David Thompson, who is responsible for the Elder Care Program and Palliative Services. Providence Health operates five long-term-care homes for approximately 700 residents at four different sites in the city. "It's always been our vision to create a campus of care on the land ," said Thompson, of the six acres owned by Providence Health where Youville is located.

Before the centre opened in 2007, he said, members from the non-profit board that operates the centre visited traditional nursing homes and discovered that the lounges that were built for seniors were seldom used. "I remember going to one place where there was a screened-in porch that was packed. The seniors were all there wanting to watch the soccer game of the school next door ," he said. Having services like doctors'offices, dentists, a daycare, a full-service restaurant, and hair styling shop on site fulfil the centre's mission of being an "inter-generational meeting place which fosters personal and community well-being." Fontaine said it's worth noting that Niverville was able to "pull all of this together in a community with a population of less than 5,000 people." He hopes more B. C. nursing homes follow Niverville's lead.

Elim Village in Surrey, which offers all levels of residential senior care on its 25-acre site, is on that track. There are 250 independent living units, 109 assisted living units and 193 traditional nursing home beds. The village also has a 500-seat auditorium, located in the centre of the village, that hosts weddings and is available for rent for other public events. Elim Village also rents out space in one of its 10 buildings to a school, which allows inter-generational programs to take place easily between students and seniors. Another "continuing care hub " at Menno Place, in Abbotsford, has a public restaurant called Fireside Cafe, popular with staff from nearby Abbotsford Regional Hospital and Cancer Centre. There's also a pharmacy and hairdresser on its 11-acre "campus " site but these services are available only to the 700 residents and staff. "We purposely try to involve the community as much as possible ," said Menno Place CEO Karen Baillie. "It's Niverville on a smaller scale." She said Menno Place partners with high schools and church groups and hundreds of volunteers visit regularly. "Seniors are often challenged with isolation and fight depression. That's why we have different programs to encourage them to socialize ," she said.

Research shows 44 per cent of seniors in residential care in Canada have been diagnosed with depression, and one in four seniors live with a mental health problem, such as depression or anxiety, whether they live in their own home or are in residential care. A 2014 report by the National Seniors Council found socially isolated seniors are at a higher risk for negative health behaviours including drinking, smoking, not eating well and being sedentary. The report also found social isolation is a predictor of mortality from coronary disease and stroke, and socially isolated seniors are four to five times more likely to be hospitalized.

Since more seniors now remain in their own homes longer those who move into care homes are often more frail and need a higher level of assistance, said Menno Place director of communications and marketing Sharon Simpson. Seniors with dementia, in particular, can be socially isolated as friends and family often find it more difficult to visit them as they decline, she said. But Simpson said an intergenerational dance program, run by ballet teacher Lee Kwidzinski, has been a wonderful opportunity for seniors with dementia to be connected to the community. The program is also offered in four other nursing homes in the Fraser Valley. "For them it's an opportunity to see children. You can see the seniors come to life, smiling and giggling at the girls'antics. It's very engaging ," she said. "Some may not be verbal but they are still able to connect. They feel their emotions and they know whether someone is good to them. They feel these girls and become vibrantly alive. It's one of the most powerful things I've ever seen."

The centre hosts 100 weddings each year. As well, about 50,000 visitors drop in at the centre annually to access their doctor's office, dentist and pharmacist or visit the full-service restaurant and pub. "We found seniors don't want to be retired to a quiet part of the community and left to live out their lives. They want to live in an active community and retreat back to their suite when they want that peace and quiet ," said Niverville Heritage Centre's CEO Steven Neufeld.

He said the plan is to build another facility nearby, with 320 traditional nursing home beds. One of the ways to partly fund the cost is to include facilities that could be rented out by the larger community, which would be a benefit to the seniors as well, he said. There is already child care on site, and future plans to help draw in the community include a restaurant, retail space and an art gallery. He said another idea is to partner with nearby Eric Hamber Secondary School by providing a music room for students to practise.

"Cambie is at our doorsteps. If you have people coming in (to a residential care facility) it brings vibrancy and liveliness ," Thompson said

inevitably taken, minimal care is given and more family involvement is required for basic care. Staff shortages in all areas touching patient care contribute to errors, which directly impact patient care. Nicole Beggs retired RN, Ottawa

But let's not be too hard on those economists. The rest of us don't pay that much attention to workers such as Shireen Luchuk either - not, at least, until our families need her. And not until someone such as Elizabeth Tracey Mae Wettlaufer is charged with murdering eight residents in Ontario nursing homes. Then we have lots of questions: Who is overseeing the care of our seniors? Are our mothers and fathers safe? Will we be safe, when we end up there?

The question we might try asking is this: If the care that Luchuk offers is so valuable, why don't we treat it that way? Dr. Janice Keefe, a professor of family and gerontology at Mount Saint Vincent University and director of the Nova Scotia Centre on Aging, says "the emotion attached to these jobs removes the value."

Caregiving, Keefe says, is seen "as an extension of women's unpaid labour in the home." Those jobs are still overwhelmingly filled by women. And, while times are changing, the work they do is still mostly for women - whether it's the widows needing care who are more likely to outlive their husbands, the working moms who need child care or the adult daughters who are still most likely to carry the burden of aging parents.

Yet it's as if society wants to believe that professional caregivers should do their work out of love and obligation - as if care would be tainted by higher pay and better benefits. That's an argument you never hear for lawyers and accountants. It's certainly not one that Adam Smith, the founding father of political economy, made for the butcher or the baker.

In last year's book, Who Cooked Adam Smith's Dinner?, Swedish writer Katrine Marcal argued that the market, as Smith and his fellow economists conceived it, fails to accept an essential reality: "People are born small, and die fragile." Smith described an economy based on self-interest - the baker makes his bread as tasty as he can, not because he loves bread, but because he has an interest in people buying it. That way he can go to the butcher, and buy meat himself. But Smith missed something important. It wasn't the butcher who actually put the dinner on his table each night, as Marcal points out. It was his devoted mother, who ran Smith's household for him until the day she died.

Today, she'd likely be busy with her own job. But care - the invisible labour that made life possible for the butcher and the baker (and the lawyer and the accountant) - still has to be provided by someone. Society would like that someone to be increasingly qualified, regulated and dedicated, all for what's often exhausting, even dangerous, shift work, a few dollars above minimum wage. One side effect of low-paying, low-status work is that it tends to come with less oversight, and lower skills and standards. That's hardly a safe bar for seniors in residential long-term care, let alone those hoping to spend their last days being tended to in the privacy of their homes. We get the care we pay for.

It's not much better on the other end of the life cycle, where staff at daycares also receive low wages for long days, leading to high turnover. "I am worth more than $12 an hour," says Regan Breadmore, a trained early-childhood educator with 20 years experience. But when her daycare closed, and she went looking for work, that's the pay she was offered. She has now, at 43, returned to school to start a new career. "I loved looking after the kids. It's a really important job - you are leaving your infants with us, we are getting your children ready to go to school," she says. But if her daughter wanted to follow in her footsteps, "I would tell her no, just because of the lack of respect."

It's not hard to see where this is going. Young, educated women are not going to aspire to jobs with poor compensation, and even less prestige. Young men aren't yet racing to fill them. Families are smaller. Everyone is working. Unlike Adam Smith, we can't all count on mom (or a daughter, or son) to be around to take care of us. Who is going to fill the gaps to provide loving labour to all those baby boomers about to age out of the economy? Right now, the solution is immigrant women, who, especially outside of the public system, can be paid a few dollars above minimum wage. That's not giving care fair value. It's transferring it to an underclass of working-poor women. And it doesn't ensure a skilled caregiving workforce - all the while, as nurses and care assistants will point out, the care itself is becoming more complex, with dementia, mental illness and other ailments.

Ideally, in the future, we'll all live blissfully into old age. But you might need your diaper changed by a stranger some day.

Maybe robots can do the job by then. Rest assured, you'll still want someone such as Luchuk to greet you by name in the morning, to pay attention to whether you finish your mashed-up carrots. When she's holding your hand, she will seem like the economy's most valuable worker. Let's hope enough people like her still want the job.

That's the premise of a new book from public policy expert, Richard Saillant. A Tale of Two Countries focuses on the impact of our aging population and warns that without a big boost in funding, the region's health-care system could collapse under the strain within a decade.

Day’s outreach efforts — like his legal battle — have contributed to shifting the public debate. Whenever he can, Day argues private health care must be expanded in our province.