Policy-making occurs where opposing ideas, differing values about who should do what, and debate about power dynamics over who should benefit and under what conditions flourish. Some policy issues are more easily resolved and receive broad consensus, if not total agreement. They operate in a virtuous cycle. In contrast, some policy areas never get to a virtuous cycle, and long-term care (LTC) is a prime example of this. Across Canada, it has remained a wicked policy problem, which, as Brian Head reminds us, is characterized by “conflicting values and perspectives, uncertainties about complex causal relationships, and debate about the impacts of policy options.”
If we look back only two decades, we might shake our heads, slap our foreheads or break down in tears, angry and frustrated at the countless government commissions, inquiries and inquests, and the innumerable stakeholder and independent academic reports that have been released ─ only to gather dust. If we retreat longer into the past, our dismay may increase as we recognize that this is a problem we have never gotten right, despite the many proposed solutions.
COVID-19 turned a wicked problem into a deadly one. Doing nothing is not a policy option this time. We recommend a three-faceted, forward-looking approach. We need to 1) implement a new set of national principles based on values to shape seniors’ care; 2) recognize, through federal funding, that we share risk for LTC, because a person’s needs can progress beyond the capacity of any single family to manage; and 3) enable a shift away from the idea that care is a commodity, toward a recognition that good care requires decent working conditions, as well as greater public oversight, to produce the needed public benefit.
From the vicious….
Why does LTC remain stuck in a vicious cycle?
Part of the policy complexity rests with LTC services being at the confluence of health care, social care, housing, disability and labour, and also crossing multiple levels of government. LTC is a sector that should, but often does not, span ministerial boundaries. While it is mostly adults older than 85 who live in LTC facilities, depending on the province there are also many other adults who reside in them, which can create challenges if the model of care is insufficiently individualized. What is more, LTC sits outside the Canada Health Act ─ it is defined as an extended service ─ and is therefore not subject to its principles. Each province and territory determines its own funding for LTC and home care.
There is far too little recognition of the extent to which complex care has shifted away from hospitals to LTC in the past two decades. This slow evolution has been traced in report after report, with little recognition that LTC can and should be considered essential. This is especially critical when the demands and chronic-care need associated with diseases like Parkinson’s, or neurocognitive conditions such as dementia, progress in ways that can outstrip the capacity of even the most well-resourced individuals and families to provide care.
In addition, LTC facilities as workplaces are associated with myriad problems, as ministries of labour and worker’s compensation board reports show. To start, care work is poorly paid, in part due to assumptions that anyone should know how to care for others. There is a lack of recognition of the highly skilled nature of LTC when it is done well; there is a persistent belief that LTC is low-value because it is largely done by an unskilled, mostly female and increasingly racialized workforce. This gendered workforce is provided with only bare supports and resources to do the job adequately, safely and with the sense of fulfillment that many went into the profession seeking. In short, we pay, provide and protect too little and generally expect too much.
There are some very good LTC providers who invest in resident life, their buildings and their workforces and offer high-quality care, but underinvestment by governments and other organizations means that the high-quality ones are good despite the LTC system, not because of it. There are far more LTC providers that are mediocre at best, and abysmal at worst. As a result, there has never really been a golden age for LTC in Canada. But the failure does not rest solely with the providers of care because, in terms of funding, long-term care has always been the sacrificial lamb to our universal acute-care health system, when compared with the funding levels that come from Canada Health Act-protected insured services.
Different values may also be at the heart of why LTC is such a persistently wicked problem. To be sure, it evokes strong reactions. Some people are appalled at its very existence and advocate for almost everyone to remain at home, mostly reliant on a kin system of gendered, unpaid care provided by women, supplemented by home-health supports. Others see the provision of high-quality LTC as a crucial resource in a society that values older people. When done well, shared living is not simply about bodily needs, it can also overcome the worst aspects of social isolation, and value women’s paid and unpaid contributions.
Finally, there are those who value profit above all else and view LTC as a lucrative market space with very stable, government-backed profits, albeit with high barriers to entry. It is not publicly funded in its entirety. Across Canada, LTC is defined by varying levels of public funding and rules for out-of-pocket payments. To add to this, even in good times, there has been an air of austerity that surrounds it. The sector has never quite shrugged off its poorhouse origins, with the implication that it is undeserving of public funding, or the sense that families are failing to live up to their obligations.
Consequently, given the value- and power-laden fights over who should do what, who should benefit, and under what conditions, LTC languished until it reached an absolute crisis in 2020, when COVID-19 ripped open the doors and shamed us all.
…to the Virtuous
Despite the calamity of the past year, there has never been as much public attention paid to LTC as in this moment, nor have we ever been as close to consensus that we can and should do more to disrupt the vicious cycle in the sector. Below, we raise three facets of what we need to do as a nation to overcome the tragedy that COVID-19 so ruthlessly exploited. First, we must create a set of national principles for seniors care that are values-based and that recognize the central place of care within our society, not apart from it. National standards, as promised in the most recent federal budget, might be necessary, but they are certainly not sufficient on their own. Standards are usually focused on organizations and providers, so they tend to be more technical and medical. We need values-based principles to which governments must be held to account. Clearly, iron rings do not work, and over-medicalizing LTC is not appropriate either. National principles could build on ─ but must move beyond ─ the Canada Health Act principles, to recognize the significance of the social and cultural spaces that long-term care residents and workers inhabit.
Second, we must recognize that high-quality, publicly funded LTC has to rest on shared risk ─ on our interdependence ─ so we are elevated toward a societal ethos of care. LTC is needed by those with high-care needs, but the “bar” for long-term care needs must incorporate the fact that some people require care sooner; some have fewer social, familial or financial resources to draw on; and some have needs that exceed the capacity of kin and friend networks.
Finally, and most importantly, we must stop commodifying care. Decommodifying care means shifting it away from remunerating a transactional, commodified regime toward offering incentives to providers to innovate and deliver high-quality care; and punishing those who cannot perform. Mediocrity should not be the standard for the provision of high quality care and decent working conditions in LTC. Decommodifying care acknowledges the vital role of public LTC. This means public oversight that includes more robust public reporting of facility-level staffing outcomes and workplace indicators; the generation of health- and social-care data including quality of life, community engagement, improvement and innovation, and comparative system performance indicators; and the establishment of clear reporting of ministerial and operator performance. Meaningful public indicators would move us toward better accountability. National principles could guide policy-makers in their decisions.
Decommodifying care also means identifying how care work exploits gender and racial inequities in society. To address inequities, we must make the conditions of care work not only publicly visible through facility-level workplace indicators but also more highly valued with good working conditions. Care workers deserve good working conditions, which include but are not limited to permanent work, extended benefits, and a living wage. They must also have the resources to do the work and to protect themselves, so the job brings personal satisfaction and minimizes poor work-related health outcomes. Ultimately, the only way to improve care is to ensure more robust public reporting of data.
As we move forward, we must be guided by a set of national principles that build on the idea that we are sharing risk for a challenge too large for any one family to solve on its own, as well as a commitment to decommodifying care for the direct benefit of residents, their families and frontline workers. Until policy-makers acknowledge these three facets to this complex and wicked problem, they will not be able to create the conditions for high-quality care or ensure good working conditions. No matter what national or provincial standards are enacted, what financial incentives exist or what funding algorithms are applied, two ideas are foundational: providing good-quality care is relational and involves treating residents and their families in ways that are not transactional; and ensuring work is decent means providing not only a living wage and job security, but also job satisfaction for care workers.
Resolving the wicked problem of LTC requires multiple levels of government, as well as the broader public and providers, to wake up, stand up, stop shifting the blame and not look away. It will require shifts in policies, practices and philosophy. At least we know one thing: unsolved wicked problems portend even more wicked problems.
This article is part of the Kick-starting Reform in Long-Term Care special feature.