I now call this meeting to order.
Welcome to meeting 20 of the House of Commons Standing Committee on Health. Pursuant to the orders of reference of April 11 and 20, 2020, the committee is meeting for the purpose of receiving evidence concerning matters related to the government's response to the COVID-19 pandemic.
In order to facilitate the work of of our interpreters and to ensure an orderly meeting, I would like to outline a few rules to follow.
First, interpretation in this video conference will work very much like it does in a regular committee meeting. You have the choice, at the bottom of your screen, of floor, English or French. If you will be speaking in both official languages, please ensure that the interpretation is listed as the language you will speak in before you start speaking. For example, if you're going to speak English, please switch to the English feed and then speak, and if you are going to speak French, switch to the French feed, and so forth. This will allow better sound quality for interpretation.
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Before we get started, could everyone click on their screen in the top right-hand corner and ensure they are on gallery view? With this view you should be able to see all the participants in a grid-like fashion. It will ensure that all video participants can see one another.
I would now like to welcome our witnesses.
We have, from the Canadian Association of Retired Persons, Ms. Marissa Lennox, chief policy officer; from the Council of Senior Citizens' Organizations of British Columbia, Ms. Gudrun Langolf, the immediate past president; from the Conseil pour la protection des malades, Paul Brunet, president; from the Office of the Seniors Advocate of British Columbia, Isobel Mackenzie, seniors advocate; from the Canadian Association for Long Term Care, Jodi Hall, chair; and as individual, Pat Armstrong, distinguished research professor of sociology, York University.
We will begin with the Canadian Association of Retired Persons and the Council of Senior Citizens' Organizations of British Columbia. I understand that they will share the slot, with five minutes each.
Please go ahead, Ms. Lennox, and I'll signal you at the halfway mark.
I'd like to thank all of you for having me here.
Ms. Hall, it's so nice to see you again. We spoke together in front of the HUMA committee.
CARP is a national, not-for-profit, non-partisan organization with 320,000 members who come from every province and territory across Canada. It's important to distinguish that while a lot of our members are retired and enjoy above-average education and income, an overwhelming majority consistently support that CARP represents the interests of all older Canadians across Canada. We believe all older adults deserve to live in dignity and with respect, regardless of income level, family support and health challenges.
It is with the following areas of health care that COVID-19 has undermined these fundamental principles of aging well and revealed a lack of planning and preparation that would secure the health and well-being of seniors during a pandemic.
The first and most obvious area is long-term care. If COVID has revealed anything, it has revealed that we warehouse seniors who are frail and very ill in unsafe situations that are underfunded and understaffed, including those who often have little or no certified training. We expect individuals and/or their families to pay a significant part of the privilege to be in those facilities. We placed both residents and staff at immense risk by not prioritizing the availability of PPE in long-term care soon enough. Too often, health system planning stops at the budget line of what government funds. We think it's time we reconsidered this during a pandemic.
It is unconscionable that of 5,000 deaths in Canada so far from COVID-19, 82% were among a population we are duty-bound to protect, and we failed. This is not the responsibility of the federal government alone, but it is the duty of the federal government to make sure that it doesn't happen again. If we've learned anything, it's that we didn't have a real plan in place for seniors in long-term care in this kind of pandemic. This is despite having advance warnings from other countries, seeing previous crises of similar scale like SARS and MERS, and having experience with seasonal influenza that spreads in these settings and claims seniors' lives annually. These are our most vulnerable members of society. We can and we must do better.
The second area is home care supports. CARP has long been examining the positive outcomes of other countries around the world who have met the challenges of long-term care with innovative solutions in leveraging home care options. Denmark, Norway and Finland are a few examples. In Canada it's reported that at least 20% of residents in long-term care could have their needs met at home.
That said, for those who are leveraging community-based home care supports with personal support aides, workers, and other in-home supports, several issues arose as a result of COVID-19. The first was the lack of PPE, which, along with the cross-utilization of personnel between retirement care homes and individuals requiring in-home support, contributed to a greater rate of community transmission in both settings. There was a clear lack of direction and guidance for caregivers and family supports, reinforcing the fact that in-home caregivers were not considered a part of the pandemic response.
The third issue I'd like to raise is the surgical backlogs. Many diagnostic, treatment and surgical activities have fallen victim to the focus on COVID-19. It includes a reluctance by Canadians to seek treatment for new non-COVID symptoms. This is not just a possibility; it is very much a reality today. CARP fears what this might mean for the health of our older populations who suffer from chronic conditions as well as such life-threatening disease conditions as cancer and cardiac care. Attention to this backlog, and conditions requiring such care, need to be prioritized.
If I have time, I'd like to draw your attention to two more things.
We are part of the Council of Senior Citizens Organizations of B.C. We are the largest independent, volunteer-run and operated federation of seniors organizations in British Columbia. We have approximately 100,000 members and we come from all socio-economic backgrounds. We are very proud to be non-profit and to accept no commercial sponsorships, for example, donations from pharmaceutical companies or for-profit service providers.
As citizens and senior citizens, we are proud and extremely grateful that Canadians have responded to the call for action to reduce the transmission of the virus to others, and especially to vulnerable people like us, seniors. We thank you for all of your efforts in dealing with this unprecedented health crisis that caught many of us by surprise. The opportunity to let you know our thoughts and recommendations about long-term care in particular and seniors' health care in general is very welcome.
By the way, we appreciated your report on national pharmacare and are looking forward to some fruition from that.
Almost half of the COVID-19 related deaths in Canada have been of seniors living in institutions that masquerade as care homes. Appalling conditions that came dramatically to the public's attention existed for several shameful decades long before this pandemic. Much of public policy seems to be based on baked-in anti-age prejudice, much like racism or sexism. Combatting and eradicating discrimination based on age will take concentrated, systemic attention over time.
No seniors we know are looking forward to going into care. That's because there is a real reluctance to go into a warehouse to wait for the inevitable end, and everyone has heard a bad story or many more. In an unprecedented effort to consult with seniors in care, our British Columbia seniors advocate interviewed as many residents as possible. A large number of the interviewees were somewhat reluctant to voice specific complaints beyond the ones about regimented time, lack of showers and that sort of thing. As well, and very telling to us, was that a huge proportion of them confessed that they really did not want to be in there. The reports are available online, by the way, so I won't go into parsing the data.
Mistreatment and neglect of seniors represents a violation of the basic human right to security of the person. Allowing that discrimination to exist and flourish is a result of chronic underfunding of health care of seniors and other vulnerable people in Canada; accelerating privatization and commodification of seniors care; non-existent or ineffective government oversight of international investments in seniors care; no consistent, enforced national standards for care; and a lack of nationally coherent, shared vocabulary describing services provided or offered to seniors.
We call for the complete reform of long-term care provisions in Canada and for independent seniors’ organizations like ours to be consulted in the process. Our recommendations are as follows:
One, that the federal government immediately begin transformational reform of long-term care laws, regulations, practices, and funding levels. Two, that the federal government initiate a national inquiry into the ongoing privatization of seniors health care. Three, that seniors health care in long-term care as well as allied care facilities become part of the Canada Health Act. Four, that government ban international investment in private long-term care homes, and phase out private ownership of long-term care homes. Five, that federal and provincial governments ban the contracting out of essential services that protect the health and safety of seniors. Six, that national principles and standards be grounded in national and international human rights legislation and be developed specifically to protect the human rights of seniors in long-term care in Canada. Seven, that accountability and enforcement measures be developed based on national reporting systems for regular monitoring of the provision of seniors care, and that a Canadian seniors advocate be appointed to monitor the implementation of these changes and to report directly to government.
It is clear that no one with the power to make any changes listened to seniors themselves until now. If they did, there is no evidence that things have changed. The fact that almost half of all the deaths from COVID-19 in Canada are of institutionalized seniors is a wake-up call for Canadians.
From the documents and information obtained, our analysis shows that the public health emergency in Quebec, which the Quebec government declared on March 13, 2020—nearly two months after the World Health Organization, or WHO, issued its first warning—did not include screening or testing in residential and long-term care centres, or CHSLDs, retirement homes or private seniors' homes.
However, by then, the WHO had already issued four warnings and Quebec's minister of health and social services had received a confidential memo on the concerns regarding seniors, not to mention the dozens of news reports around the world, including several in France and the United States, warning about the risks related to seniors and retirement homes.
The same documents and information obtained reveal that, prior to March 13, 2020, the health minister's own chief of staff, Mr. Valois, stated that, although preparations were beginning slowly, it wasn't an all-out effort to prepare for battle at that time.
With the public health director, Dr. Horacio Arruda, on vacation in Morocco for a few days in late February, and even the premier, Mr. Legault, on vacation until March 8, it would seem that, in Quebec at least, COVID-19 was not considered a national emergency requiring that senior patients be identified, tested, isolated and treated.
At least, that is what the lack of screening, isolation and treatment measures recommended by the WHO since the beginning of February, particularly with respect to seniors in CHSLDs and retirement homes, suggests.
It was only three months later, on April 7, 2020, after four WHO warnings and a private memo to the health minister on the hundreds of news reports around the world, that the Quebec government finally decided to do something about seniors in CHSLDs and retirement homes. In Quebec, 81% of COVID-19 fatalities were residents of CHSLDs or private retirement homes.
On April 7, the Quebec government issued a news release in which Premier François Legault stated that his priority was to protect seniors. On April 10, 2020, as though they had been living under a rock, Mr. Legault's staff learned that COVID-19 was spreading like wildfire among seniors in CHSLDs and retirement homes. That was nearly three months after the WHO's first warning, the last of which came on March 1.
Moreover, “Early reports suggest that illness severity is associated with age...and co-morbid disease.” This is from the March 1, 2020.
In our view, the Government of Canada and the authorities responsible for the administration and health and safety of Quebec's CHSLDs, in particular, failed shockingly in their duty to prepare for health crises like COVID-19. They delayed introducing measures to test and treat the residents and staff of CHSLDs, as the WHO had been recommending since February 5 and March 1, 2020.
It is our position that they have violated the basic rights of thousands of Canadians and Quebeckers, people who were entitled to the right to life, including the right to receive life-saving care, to have bedsores treated, to be properly nourished, to be able to drink when thirsty and to be hydrated. Emergency doctors in Quebec told us that patients were hospitalized, not because of COVID-19, but because of dehydration and malnutrition.
These are people who had the right to integrity of the person, the right not to be housed with infected people, and when severely disabled, the right not to be lifted or changed by often well-intentioned but incompetent staff or volunteers. They had the right to dignity, the right to be treated like a human being, the right not to be left wearing a soiled diaper for days, the right to have assistance to use the toilet, the right not to be abandoned and the right not to die alone without dignity.
The authorities responsible for Quebec's CHSLDs were not prepared for COVID-19, despite recommendations by the Public Health Agency of Canada and the public health protection branch within Quebec's ministry of health and social services dating back to 2013.
How could the Canadian and Quebec governments have left seniors in these conditions and not responded sooner to the WHO's warnings and the information coming out of a number of countries around the world?
Thank you for inviting me to give my thoughts and observations on our initial response to COVID-19 as it relates to seniors. I say “initial response” because we're not through it yet. Inevitably we're going to discover some future issues that are not obvious right now. As you know, we're only two and half months into what is going to be a year long or 18-month journey.
I think most of us have seen, as we have responded to this pandemic, that fault lines have appeared that relate to a lot of things in our society and our economy, but particularly as they relate to seniors. I think we need to recognize that the impact of COVID-19 is different for seniors depending on their income, their social and health status. What one senior experiences in not necessarily what every senior is going to experience.
I've tried to break it into categories to look at where these differences are. If we look at the category of low-income seniors, I think there has been a different impact on them than other aspects of society. As most of you probably know, seniors have the lowest personal income of any age cohort over 25. They are very sensitive to small cost increases.
It's true that seniors have not yet felt an impact from a decrease in income. Pensions obviously have remained the same. Impacts from investment income haven't really been felt yet. The degree to which that will be felt is still to come. I'm sure many MPs on this committee have constituents who are low-income seniors who are sensitive to price increases. I'm sure you've heard about the experience of increases in food costs, in part because of actual increases in food, and in part because seniors who normally go from supermarket to supermarket or store to store looking for specials have not been able to do so. A $50 or $60 a month increase in the food bill of a low-income senior's budget does have quite an impact.
Low-income seniors are also less likely to be savvy in the virtual connections we have, like Zoom, in part because they are less likely to have devices and they are far less likely to have the Internet. One of the things that the federal government can look at in the future is how we're going to be able to provide low-cost Internet. We have focused a lot on the provision of the Internet to all parts of Canada, including rural parts. That is very important. We cannot ignore the fact that the Internet is also very expensive, especially for low-income people, and particularly for low-income seniors who can't necessarily bundle everything together on a smart phone.
I think the impact on low-income seniors wasn't immediate. It wasn't on day one, but it has compounded over time. I think it will continue to compound as they are susceptible to these small price shocks that I think we're going to see over the next year.
As we practise our safe distances, our six feet apart, as we isolate at home and certainly as seniors are made aware of the need to stay away from people more so for them than others, we need to recognize that seniors are more likely to live alone. Indeed, 23% of people 65 to 85 live alone. That goes up to 41% when you look at people 85 and over. Compared with the population under the age of 65, less than 10% between the ages of 35 to 65 live alone. When you're socially isolating in your own home, it looks different when you have a partner or kids to talk to versus having nobody to talk to. I think we have to be sensitive to that impact, which is going to build over time. You're not going to notice it as much in week one or week two, but as the weeks become months, I think we're going to have to recognize the profoundly disproportionate impact on seniors because they are disproportionately likely to live alone.
The COVID-19 response looks different depending on your health status as a senior. If you're 65 or even 90 and you're robust and living independently and can perform all your activities of daily living and your independent activities of daily living on your own and you're living with your spouse and you have sufficient income, that looks one way. It looks not unlike how many of the rest of us are responding to COVID-19. However, if you are like the majority of seniors over the age of 85, you need some help with your activities of daily living and perhaps even with your independent activities of daily living, so you're going to feel an impact. Certainly Marissa, and I suspect others, will talk about home care as well and how the availability of home care and the impact of COVID-19 on its delivery is going to affect some seniors.
COVID-19 will also have a mental health impact on some seniors as it dawns on them just how vulnerable they are when they need some help with their activities for daily living. They may not have appreciated it when they were getting the steady flow of home care, but as it became apparent that there might be some challenges in having that continue, I think there might have been an undercurrent of additional anxiety among some seniors as they recognized how vulnerable they were going to be when living alone without the ability for others to come in and help, although to the best of my knowledge we didn't see that big of an impact. Certainly here in British Columbia, we fortunately did not see an impact on home care services for seniors living at home.
There are also those who are in assisted living and in the long-term care system. For them, the economic challenges aren't profound, but the other challenges have been. Number one is the fear, but there is also the inability to visit with family members, which is still the state of events here in British Columbia and I think in every other province to date. Hopefully we will find a way to reintroduce some capacity for family visits in a way that's safe so that over the next year, we can allow some of the connection to happen that's been lost over the last couple of months. That has had a profound effect.
There are also the family members of those living in long-term care and assisted living. They will be profoundly affected on two fronts: in their inability to visit their loved ones and in what they are hearing, seeing and learning about what is happening in parts of our long-term care systems. I think it is important to acknowledge and understand that many care homes have had no outbreak of COVID-19, and some that have had outbreaks of COVID-19, like those here in British Columbia in the last month or so, have been able to swiftly contain their outbreaks. I think it's important to remember—and Gudrun talked about when we went out and surveyed residents in long-term care pre-COVID-19—that while many of them do not want to be there, do not feel it's home-like and do not receive the kinds of things they want to receive, many do as well.
I found it interesting when we went out and surveyed all of our care homes. I don't think it had been done to this magnitude in any other province. Every single publicly funded care home, every single resident and every single family member was surveyed by my office, independently of the care home and the health authority, and literally 50% of them said home care was pretty good and 50% said it was not very good. Many of those people were in the same care home.
We have to appreciate and understand that your experience in a long-term care facility is linked to a number of things: your expectations and experiences before you went into a long-term care home and your health status in a long-term care home. Not surprisingly, levels of dissatisfaction rose as levels of complexity rose. The more help you needed, the less satisfied you were. The less help you needed, the more satisfied you were. I think that speaks to some of the fault lines that have been very publicly revealed now in the staffing levels and staffing models that we have in long-term care throughout Canada. Those folks have a different experience with COVID-19.
What are the major challenges that we have? Certainly, I want to start at the income level. There is no doubt that for about a third or maybe 40% of Canadian seniors, income is a problem. Many seniors have sufficient income, arguably more than sufficient income, but we can't forget....
One measure that I use is the GIS measure. If a senior is on GIS, they have a pretty low income. It's linked to their—
Thank you for the opportunity to speak to the committee this evening.
The Canadian Association for Long Term Care is the leading voice for quality care in Canada. Our members deliver publicly funded health care services to seniors right across the country.
I will start by acknowledging the seniors who have died of COVID-19. Our hearts are with those families. I'm sure that you all join me in extending deepest condolences to them.
I'll also take this opportunity to thank our front-line health care providers, who have worked tirelessly and with great compassion to deliver the care that has been required.
As we reflect on COVID-19, we will take the time to understand what could have been done differently, but we believe the impact of COVID-19 on long-term care homes could have been mitigated if governments had been proactive in supporting the sector prior to this outbreak.
Some of the challenges I will be discussing today have been exacerbated by COVID-19 but really represent systemic issues our members have been raising for many years. I want to be clear that all types of homes have been affected by COVID-19 and each have had a different type of experience. This has been an extraordinarily difficult and painful time for everyone involved, including residents and families, the front-line staff, but those who operate long-term care homes as well. We just ask that the efforts of the nation continue to focus on rallying and supporting those who are in long-term care homes.
The differences in experience with the virus have been based on a range of factors. These factors have included infrastructure, the staffing situation in the homes both pre-outbreak and during, and how rapidly the homes have been able to access personal protective equipment and staffing support when they really needed that assistance.
In the early days of the pandemic, testing, the ability to cohort their residents, and infection control measures were focused on seniors and caregivers who showed symptoms. Infection control experts and public health scientists now understand that asymptomatic carriers are highly contagious and that the incubation period for COVID-19 is far longer than for other viruses. As a result, homes that were affected early by the virus seem to have been hit the hardest.
I'd also like to clarify some misconceptions. Any and all care that is provided in long-term care homes, whether that care is provided by a doctor, a nurse or another type of health care provider, is covered by provincial governments. Each province regulates long-term care a bit differently, but generally the homes receive a funding envelope for care, programming and staffing.
In Ontario, for example, the government funds all long-term care homes with highly prescriptive expenditures, which are audited through the government departments that oversee them, and the findings of those audits are always reported back to government. With every dollar that is allotted to nursing, to personal care and to food budgets that are specifically earmarked, if there are any dollars left over in those envelopes, they have to be returned to the provincial government; there is no profit on any of these funding envelopes.
In other areas of operation, the staffing levels are highly prescribed and the funding model is extremely complex. It's highly prescriptive, tightly regulated and monitored on a regular basis by each provincial government.
I will now speak to some of the systemic issues we have noted that we feel have been an exacerbating factor with COVID-19.
The first one is infrastructure. Many older long-term care homes have three- and four-bed wards. They do not have private rooms, and it makes it a challenge to implement cohorting and isolation measures. They generally have narrower hallways and there's only one centralized dining room in the majority of homes, which makes it much harder to socially distance residents appropriately.
The Public Health Agency of Canada released an interim guidance document on infection control for long-term care homes, and some of the guidelines such as restrictions to certain work zones and the use of single rooms for certain types of care are almost impossible for homes to implement across the board, especially in these older facilities. Any existing outbreak management plan that these older homes have, including the isolation of asymptomatic residents, is really hindered by inadequate space and the layout availability, and we can see just how devastating shared rooms can be in an outbreak.
We know that there are at least 400 long-term care homes across the country that require updating and some form of modernization. It is imperative that the federal government support this sector by providing access to existing federal infrastructure funding, and there are many ways this could be administered. We have also noted that recently spoke about financial support for shovel-ready projects in the post-pandemic stimulus package. These projects, indeed, are shovel ready and we certainly could move forward quickly with federal support.
The other systemic issue that I would like to raise is with regard to health and human resources. This is a challenge that is facing this sector and is ongoing almost at a crisis level across the country. Attracting and retaining individuals for a career in senior care has become increasingly challenging, especially when preparing for the aging demographic transition that we're experiencing right across the country. We're caring for individuals who have multiple and complex conditions much more than we have seen in the past.
We are asking for a health and human resources strategy for the long-term care sector. This is desperately needed and it should focus on the right number, the right mix, the geographic distribution of providers, as well as an appropriate setting for providers to deliver the care in. Through the leadership of the federal government, there must be collaboration with the provinces, the territories and the long-term care sector to develop and implement a pan-Canadian health and human resources strategy.
In closing, there are systematic challenges that the sector has been grappling with for many years, which we have identified. This has been fully exacerbated by the event of COVID-19. We have asked before, and we are asking again, that the federal government provide assistance to the sector to ensure that seniors have the housing and the care they need, not just in a time of crisis, but every day.
I thank you for giving me this opportunity to speak, and I certainly look forward to questions.
Thank you for the opportunity to appear on this critical issue.
In the 1980s, the Ontario Pay Equity Commission asked me to study the health sector to see who would be missing from the legislation, a request that began my research into long-term residential care, or what are most commonly called nursing homes.
Most recently I've been the principal investigator on a 10-year interdisciplinary project, called “Re-imagining Long-Term Residential Care: An international study of promising practices”. This research took international interdisciplinary teams, made up of mainly senior scholars, into nursing homes in six countries: Germany, Norway, Sweden, the U.K., the U.S. and Canada. We observed, interviewed and reflected together on what we saw and heard over the week-long span we spent in each of these homes.
In this, and in a number of other related projects, we've confirmed our central assumptions, assumptions I want to set out here.
First, we need nursing homes now and in the future for those who require 24-hour care. Such care cannot be provided in private homes, not only because many people do not have homes or at least homes suitable for such care, but also because the care required is skilled and demanding. Your grandmother and mine never provided this kind of care, because few people lived into old age and even fewer lived with the kinds of conditions and technologies required today. Of course, it is primarily women, unpaid for the work, who provide care at home now, often to the detriment of their health now and in the future. We need to plan for more, and more accessible nursing homes where 24-hour care is provided.
Second, the conditions of work are the conditions of care. These conditions certainly include adequate staffing in terms of numbers, composition, training and continuity. These conditions also include pay and benefits, especially paid sick leave, and decent terms of employment, such as hours of work and shift length as well as choices about them. The conditions involve equipment that goes well beyond the personal protective equipment that has appropriately received so much attention today. It must include such things as lifts and carts, when we think about the health risk to the residents and staff.
However, the conditions for care include much more than that. Reasonable autonomy, the time to provide the care that training and experience have taught workers to provide, and support for teams are critical conditions. Union protections, especially the right to say no to on-site conditions and to the violence that is far too common, are also essential conditions. Similarly, the physical structure of the home, as we've just heard, and its location shape care.
This is not a complete list of conditions that are necessary for care. We have to take all of them into account in planning for care both during and after the pandemic. Otherwise, we will not have a labour force, as the OECD and the ILO recently made clear in their report in December.
Third, these conditions have to take into account all those who live in, provide paid and unpaid work in, and visit in long-term residential care. Our research clearly shows that it is not only direct nursing care that is critical. While there has been recent media attention on cleaning in pandemic times, there has been virtually no discussion of the laundry and dietary services that are also particularly important now but are always essential to care. Moreover, families do much more than provide the hugs that have received so much media attention. They also fill gaps in other care work, as do the privately paid companions many families provide. Volunteers, too, make critical contributions to the social activities and the physical environment, contributions that are essential to care in long-term residences.
In recent years, this unpaid work of families and volunteers, the paid work of non-staff and the unpaid work of paid staff have all expanded to fill the gaps in care, well before the pandemic. We need to address the gaps in care at the same time as we ensure that everyone who provides care has the training required.
Fourth, this is skilled, gendered work. We've heard a great deal about the heroism of these workers, which may end up like Mother's Day, a one-day recognition. Pay equity legislation grew out of research demonstrating that there is systemic discrimination in the labour force. This discrimination renders invisible and undervalues the skill, effort, responsibility and working conditions involved in women’s work.
This is definitely women’s work, whether carried out by staff, contractors, families or volunteers. More than four out of five of those employed in this sector are women, and a significant proportion are new to the county and/or are racialized. There is a faulty assumption that this is work any woman can do by virtue of being a woman. The value of and the skills involved in the labour may be further undermined by the fact that this is mainly women looking after older women.
I am reminded of an interview I did with a human resources manager of a large home in Norway. I asked her what surprised her when she went into the home after working in a major media corporation and she said, “I couldn't believe how hard these women worked.” When I asked what she would do if she was in charge of the country, she said, “I'd pay these women what we pay the men on the oil rigs, because these women work harder.”
We have to recognize this work. We have to support it as skilled, demanding work that carries considerable responsibility. We have to do so not just now but in the future.
Fifth is that context matters. We talk about promising practices in our research rather than best practices because there are often multiple ways of making care conditions as good as they can be. We can learn from other countries and jurisdictions as we recognize at the same time that what works well in Toronto may not work well in rural Nova Scotia. Nevertheless, we can establish broad principles for setting conditions, and we must do so to protect workers, residents, families and volunteers.
Sixth, the search for profit does not lead to better quality care, greater efficiency or more choice, nor do many of the practices taken from that sector. Indeed, such privatization can lead to the reverse. We have to ensure that our public money goes to care rather than to profit, and to democratic decision-making rather than shareholder decision-making. At the same time, we need standards for all homes and to make sure those standards are practised and enforced.
While there are many other lessons we have learned that would take me well over my 10 minutes, let me end by saying this all leads to the need for federal leadership, as many here have said today. I would argue that it should be through legislation that is similar and parallel to the Canada Health Act, legislation that provides conditional funding based on evidence that principles and criteria are followed.
We have a host of research and commissions that provide enough evidence and advice to move forward quickly. However, in doing so, we need to ensure that the voices of those who live in, provide paid and unpaid work in, and visit long-term residential care are heard. We must ensure that nursing homes are not only safe and accessible, but also organized, funded and designed to make life worth living for all of those who live in, work in and visit long-term residential care.
Thank you. I'd be happy to answer any questions.
When you look at British Columbia so far, there is quite a difference in the probability of an outbreak in a contracted care home versus a health authority owned and operated care home. That is a very clear pattern that's established. I think 8% of the outbreaks are in owned and operated sites, yet owned and operated sites are 37% of the sites. There is quite a difference here.
The PPE issue is, I think, complicated because part of it is the lack of understanding of the appropriate use of PPE. This is something strong clinical leadership can help in a care home setting. It's not clear. When we get all the data and we can sort through all of it and look for the patterns around that strong clinical leadership, for me, one of the litmus tests is when I hear a care home talk about N95 masks and the care home has no outbreak. You don't use an N95 mask in a situation where there is no outbreak.
There is the issue of the supply, writ large, and then the appropriateness of the use of PPE, irrespective of the supply. When we talk about our not being prepared.... I've spent 20 years in delivering both home care and long-term care, and here is my observation: We completely underestimated—for want of a better term—the freak-out factor.
We are accustomed to outbreaks in long-term care. We handle them every year. We had 185 of them last year in British Columbia. We have protocols and we notify, but those are influenza and norovirus. We completely underestimated that, when it was COVID-19, we needed....
This is where I think that, in British Columbia—because we had the first outbreak and perhaps because in the first outbreak the care home wasn't able to respond—public health got in there and saw how quickly it needed to get in there and take control, and then was able to keep doing that. I think that is what has happened in British Columbia. It is public health's going in right away. When I look at what has happened in other parts of the country, that wasn't as quick off the ground, in part because we had the first outbreak here.
Before I begin with my line of questioning, I just want to say that it's a real privilege for me to hear from the witnesses today and for all of us to hear from the witnesses today. In my riding of Cape Breton—Canso, we have a large seniors population, and I keep them in mind every day. Throughout this pandemic, I've seen just how much citizens throughout the riding have come together to support seniors in our communities during these challenging times. I want to thank each of you for the work that you're doing in this regard.
My question is for Dr. Armstrong, and this has been referenced. You wrote a report that identified staffing issues, shortages of staffing and low wages for health care workers in long-term care facilities as having contributed to the spread of COVID-19. We know that the spread of the illness, including the common flu, has been noticed very quickly throughout long-term care homes even before COVID-19.
In your research, what solutions have you concluded can address these staffing issues and can prevent the spread of communicable diseases?
Also—I think you've alluded to this—can you talk a little about the best practices that you have been able to identify that long-term health care facility administrators should be aware of?
Staffing has been identified in report after report, not just in terms of numbers but also in terms of training and distribution.
If we'd had adequate staffing levels to start with, we wouldn't have had the kind of desperation that we've seen. If we'd had full-time jobs, we wouldn't have to be introducing the kinds of practices that were introduced in B.C., because those would already be what was happening in homes. If we had surge capacity within the homes in terms of the labour force and in terms of the physical space, then we wouldn't be having this crisis either, I don't think.
We've known this for a long time, and if we don't learn the lesson from this, then I think we are going to be in worse trouble in the future. This is one of the reasons why we want to talk about the future as well as the present.
We have a lot of evidence that 20 years ago they were saying that 4.1 hours of nursing care per resident per day was essential, and that was before we had residents with the levels of complication that we have now.
Charlene Harrington, who is one of the biggest experts in the U.S. on this issue and who I was talking to this week—she is part of our research team—said that they're now saying that it should be 4.9 hours per resident per day, given the level of acuity that is the case in most homes in Canada. We don't have any province or territory that comes even close to that, and that's in regular times.
I'd like to thank all the witnesses for their insightful comments. We have to find solutions. My first question is for Mr. Brunet.
Your opening statement was very compelling. You're known for your anything but complacent attitude. It's a quality I appreciate.
On March 13, Quebec was the first to declare a public health emergency, when it had just 17 cases and no deaths. Two months later, the situation is this: the number of cases will surpass 40,000 by tomorrow and more than 3,220 people have died.
Most of the witnesses we've heard from—even some today—have told us that, early on, the weaknesses and vulnerabilities of the health care system exacerbated the rampant spread of the virus. They cited underfunding of the system as the main reason.
Many would prefer to standardize the rules from coast to coast to coast, but health care is the domain of the provinces and Quebec. You had reservations about nationalizing CHSLDs, saying you preferred that Quebec pass legislation requiring a minimum level of care and services in CHSLDs and retirement homes, whether private or public. I'd like you to elaborate on that.
Tell us, if you would, what the parameters or key pillars of that legislation should be.
You're right. Over the past 45 years, we've contributed to dozens of parliamentary committees, public consultations and, for the past 35 years, public inquiries, mainly in the area of long-term care. In terms of results, however, things haven't changed.
Long-term care is provided every single day. People need to know that these facilities offer a good standard of living. That means ensuring measures are tailored to the reality on the ground. After 25 years as a health care advocate and given what I've seen, I respectfully submit that it doesn't matter whether an institution is public or private, despite what all the scientific studies say.
I've seen miracles and horror stories in public and private institutions alike. The difference lies in the men and women who run the establishments and their ability to show leadership in bringing together residents, families, unions and health care professionals. When all of them are at the table, the difference is clear. The low number of complaints these establishments receive has shown me that it doesn't matter whether they are public or private; the men and women running them and their ability to work alongside staff are what really matter. That's the empirical evidence I've gathered after being in the field 25 years and seeing hundreds of cases.
That's what I've experienced, what I've witnessed and what I think. Unlike others, I don't claim that it's based on scientific research.
I think what the report demonstrated was that we don't have the proper financial incentives or oversight. You could argue, Mr. Davies, that, if we get it aligned, then being a for-profit operator will be of marginal value.
I can't speak for Ontario. I know Jodi was talking about the way money is managed. That's not the way it's done here in British Columbia. We give a lump sum payment to a contracted provider, and we come up with that lump sum by saying you should spend this much on this, that and the next thing. They do provide statements that say, “Here is what we spent on this, that and the next thing”, and we look at that, but we don't do anything with it.
The classic example is around wages. In British Columbia, all care-home operators are funded to provide industry-standard wage levels, so they are provided enough to pay care aides at the industry standard. Whatever they pay them less than that, they get to keep. That's the problem.
There are things we could do quickly, and what we could remedy quickly is certainly the money we're giving you to pay wages for—we call them care aides in British Columbia—personal support workers, whatever. You have to pay that, and if you don't pay it, you have to give it back. What we pay you for the nurse, you have to pay, and if you don't, you have to give it back. We take away the incentive, and by that we take away the profit. We take away the motive for making a profit.
There was a very clear pattern. As Pat said, it's a pattern, which means there are exceptions to the pattern, so yes, there will be good performers or, as the economists would say, good actors, in the private field, and there will be bad actors in the not-for-profits.
I've spoken of it and others have as well. I think the reason we are seeing at this moment better outcomes in British Columbia is because of what we learned at the first outbreak at Lynn Valley. I think the approach has been that, first of all, we lowered the barrier to declare an outbreak on one case. The normal outbreak threshold is two cases, one laboratory confirmed. Also, we looked at staff equally as residents. I don't know how many people here have been in practice, but when I was in practice we never looked at staff for influenza swabbing; we looked at residents. That, I think, has helped.
The minute the outbreak is declared, which is one confirmed case, either staff or residents, public health gets in there immediately and gives direction to the care home around all of the things that need to be done. We talk about the cohorting and about these other things.
In British Columbia, 75% of our residents are actually in single rooms. I think that is higher than other provinces. I think that has also helped us manage the best practices that PHAC has recommended, and that any infection control person would recommend.
The recognition of the care staff as the vectors of transmission and the designation to one work site, which was done earlier, has been helpful. If there's one area where we lagged a bit—and I would say everybody did, and Jodi has talked about this—it was the testing of asymptomatic people in an outbreak situation. I think we learned. Early on, we weren't doing that because the evidence at that time was that the test was ineffective if you were asymptomatic. We now know that asymptomatic people can both shed the virus and test positive for the virus. So we have started that best practice as well.
I think it's those things. Certainly, the quick, SWAT-like intervention of public health at the very beginning has been absolutely key to helping us.
Thank you very much, Chair.
Thank you to all of our witnesses today. You have valuable insights to help our seniors, particularly those living in long-term care, and obviously you feel very passionate.
I'd like to turn to the question of the physical structure particularly at long-term care homes, retirement homes. Ms. Hall, you referenced this in your remarks, and I understand you've done a number of interviews on that particular subject.
Here in York Region, in our municipal homes, actually, one was redeveloped about 20 years ago. There was sufficient space to have nearly all single rooms and a couple of double rooms particularly for couples who obviously might want to be together in the same facility. In fact, of our two facilities here in York Region, neither has had a COVID-19 outbreak.
I would ask you to talk a little more about the importance of what the government might do to assist in the redevelopment.
Okay, sorry about that.
First of all, I'd like to thank all the witnesses. You have covered a very wide range.
One of the things we have been talking about is federal leadership. My understanding is that there should have been many federal, provincial and territorial—what we call FPT—ministers responsible for seniors and looking after these. I don't know whether our current minister has done that. Definitely this is the right time, especially for the long-term care homes and other jurisdictions that are mainly provincial, yet we need to take the lead.
When we talk about seniors in social isolation, we're looking at three different groups of people: those who are in seniors homes, those who are living with their family members, and those who are living by themselves. When we look at their physical and mental needs, I think we should have different reactions.
I'd like to ask if any of our witnesses could shed some light on the different needs of these three different groups.
Maybe I could ask Ms. Mackenzie, then, about the seniors in social isolation, the three different groups.
Certainly. When we look at Lynn Valley and what happened there, for want of a better term I call it clinical leadership. Strong clinical leadership is needed, particularly now in this environment.
Community care aides are 70% of the care staff in our nursing homes in this country: personal support workers, as you call them in the east, and care aides, as we call them out west. Understanding infection control, understanding how PPE works, understanding the use of N95 masks and aerosolizing procedures was, I think, a piece that was missing.
It weaves through this issue around the care aides in our care homes. This is a place where the federal government could show leadership. I'm struck by the fact that we have national standards—not just standards, but exams—for RNs and LPNs, but we don't have any such national standard for care aides. Part of the way that you make a person feel valued, and part of the way that you attract people to something called a profession, is that you actually provide those standards.
In the 20 years that I worked predominantly with care aides—I worked with nurses and LPNs as well—they craved training. They wanted to be able to take courses. Our system is set up.... It's very frustrating. I could send my nurses on courses and I didn't have to backfill them. It was easy. If I sent my care aides on courses, I had to backfill them. That cost money, so they sort of got left behind in all of it.
I think that is an area: federal leadership around standards, not just around what happens in care homes and care ratios, but around the level of training. I am a big proponent of standardized exams. They have to be practical and written, I do understand that, and they don't tell the whole story. They do not get to the piece around the EQ—emotional quotient—that is needed to be able to provide this kind of care.
Jodi is quite right. The wrong person with the right training is as much a recipe for disaster, in fact I would say more so, than the right person with the wrong training. We have to be careful about that.
Certainly PPE is one example where, if we had better training, more high-level training, more standardized training, we could have.... A lot of concern and anxiety have been created around this. I think when we step back and look at it, we're going to realize that yes, that was important, but really there was this other piece over here. I think that is a key area where the federal government could show leadership as well.
Sure. I will try to do that.
Obviously, not everyone should be in long-term care facilities. I know that some of them are better than others, and people are more or less comfortable in them, but I think the overwhelming majority of people would prefer not to be there. In order for them not to be there, unless they have really difficult or complicated health issues that require 24-7 care, many of their needs could be met at home, if the home was adapted in a way that was going to be useful in terms of whatever their needs are.
One of the things we see is that there had been a contraction of services for home care. Not everything was covered, and there seemed to be artificial distinctions among housekeeping, meal preparation and administration of medication or therapeutics, as though they are separate. If your home is not a hygienic one, that's not going to be a good situation. I don't know how you can divorce cleaning, cleanliness, laundry services and so on from health conditions in general.
That may seem odd, but I think the services to seniors have to combine or span a whole spectrum of services that perhaps are punctuated by the end station which is, generally speaking, palliative care or a long-term care situation. That's an inevitable process of aging. All of us will face that sooner or later. Hopefully for all of us it will be later, but that's the way it goes.
I think this particular pandemic has given us the opportunity to have a critical look at, and apply some critical thinking towards, the kinds of things that would help make things better. I think that people like Dr. Armstrong and Isobel Mackenzie, and a lot of others, have developed and amassed a great deal of information. Doing more detailed studies, we really prefer not to see that happen. Gathering all that stuff together may be a good idea, and then see how it can be applied in a national way.
Seniors are running out of time. I'm in my seventies. I don't want to wait another 15 years before we tackle this sucker. It has to get fixed. We have to do it. It would be a dumb thing if we did not use this opportunity, as Isobel was mentioning. You have huge numbers of people waking up to the reality of—