Australia's COVID-19 successes shine a light on Canada's troubled long-term care sector

When it comes to the death toll of the COVID-19 pandemic, the comparison between Canada and Australia is shocking. Australia has suffered four deaths per million residents compared to more than 212 in Canada. 

Canadians have watched in horror as the COVID-19 death toll climbed in Canada's long-term care facilities, now more than 6,000, according to a CBC News tally. In Australia, that number is just 29, according to Australian public health data. 

Greg Shaw, who runs the International Federation on Aging non-profit, is uniquely positioned to compare the two countries. He lives in Toronto but previously served in senior roles in Australia's Health Ministry. He points out that Australia's aged care facilities had a detailed plan to deal with a pandemic, while Canada did not. 

"When COVID 19 came to Australia," he said, "many of the care providers basically locked-down and implemented their pandemic plans for infection control. They stopped families from coming in. They didn't have staff working from one facility to another facility, and generally that's not the case in Australia anyway."

In Canada, the fact that some long-term care workers initially had to find shifts in multiple facilities to make a living was a  significant contributor to the spread of COVID-19. Since the outbreak intensified, however, provinces have prohibited staff from working at multiple care homes. 

Inspection

One of the most striking differences between Canada and Australia lies in the inspection regime for seniors' facilities. Australia is far more strict, said Graeme Prior, who runs one the largest for-profit aged care providers in Australia.

He owns dozens of homes, and says the inspections of them are rigorous. "If we get a report for the federal authorities in six months' time from an inspection and it's a negative one, we've got 28 days to fix it," he said. "There's no mucking around. There's no 'I'll think about it.' We'd be sanctioned. We'd be out of business in six months."

Twelve homes were shut down in Australia in 2018, according to figures from Australia's public health department. Zero were shut down in Ontario that year.

"We don't seem to have the kind of teeth that they've given to their inspectors," said senior care expert Tamara Daly of York University. "We don't act as readily to shut a home down. They (Australia) remove accreditation really fast, and as a result of that, I think that they are getting better compliance with their standards."

Staffing levels

Staffing levels are a key factor in senior care. In Canada, personal support workers may have to care for as many as 36 patients, according to Daly, who finds that unacceptable. "One PSW for 36 residents who themselves are incapable of going to the toilet on their own. If someone needs two people in order to move them and they want to get out of bed, those two people have to be available at the same time. The level of staffing is just so much more limited." 

Staffing levels affect care on the most basic level such as bathing. In Australia, Prior said his residents have a bath or shower every day. "That's the way it works. You'd have your bath at six in the morning or have it at lunch time." In Ontario homes, only two baths or showers per week are required by law under the long-term care home act. 

Many trace the drop in Ontario senior care staffing levels back to the 1990s when Conservative Mike Harris was premier. Harris actually budgeted an extra billion dollars for senior care in Ontario, but his government directed 60 per cent of that money to private "for-profit" providers, and he cut staffing requirements. 

"Cutting minimum staffing has had a very negative impact on the sector overall," said Daly.

The role of Mike Harris

After he left politics, Mike Harris became the chairman of Chartwell Homes, one of Ontario's largest for-profit senior care providers. Since then, Chartwell has had staffing-level issues.

Government inspection reports show that one Chartwell home in Kingsville, Ont., has been cited dozens of times in recent years for not maintaining adequate staffing. Follow up-inspections often found that the Chartwell operators  repeatedly "failed to comply" with regulations but there has been little consequence for them.

"They're getting away because there aren't serious consequences," said Shaw. "Tell me any province in Canada where the government said 'You're not meeting the standards now. We're actually putting in an administrator to bring the care standards in the home, and the service provisions, up to standard before we will allow you to take it over again.' You've got to be able to demonstrate that you're capable of running the nursing home."

Only now, as a result of the COVID-19 crisis, the Ontario government has announced it would take over at least nine senior homes.

A crucial tool to find major problems is for inspectors to arrive without warning. In Ontario, they are called Resident Quality Inspections (RQI) and are a counterpart to reactive visits that are required after a complaint or some critical incident in a home, such as a death. RQIs catch facility staff off guard and often reveal hidden problems.

In Ontario, last year there were only nine such unannounced inspections. By contrast, in Australia, recent records show 3,099 unannounced visits in one year, at least one for each home. If Australia's approach had been applied to Ontario where there are 628 registered LTC facilities, there would have been at least 628 unannounced visits in 2019, not just nine. 

For-profit homes

Of the six worst hit seniors' homes in Ontario where the Canadian army was dispatched to help out, five were for-profit homes. 

"We know even before COVID happened that for-profit homes tend to perform worse than public homes and non-profit homes," said Daly. "We also know that non-profit and public homes pour money in and have higher staffing levels as well as better workplace protections so they have more permanent staff, they have more staff that have benefits. We also know that for-profits tend to rely more heavily on temporary and casual staff."

In Ontario, a significant amount of money spent for senior care ends up in executive compensation and shareholder dividends for the private providers. The Toronto Star reports that for Mike Harris's Chartwell Corporation, that figure was $845 million over the last 10 years. At the end of last year, he personally had a seven million dollar stake in the company.

Mr. Harris declined our request for an interview. In a statement, Chartwell said: "Mr. Harris's government added much needed additional capacity to the long-term care system and helped ensure a significant portion of buildings were able to be redeveloped to modern standards."

Daly, however, said there is, "quite a bit of profit-taking in the sector ... so we need to ask really, really clear questions about how we want public dollars used, and what we need to demand."

The political calculation

A few weeks ago, Prime Minister Justin Trudeau speculated aloud about how the federal government should get more involved in senior care. He was quickly shot down by Quebec Premier François Legault, who basically suggested the federal government should mind its own business and stay in its own jurisdiction. 

The politics of this situation may have pushed Trudeau to stay out of the sector for now, perhaps because at the moment the senior care homes are seen as a terrible problem that tarnishes any politician responsible for the mess there. 

There is some question as to whether the COVID-19 disaster in long-term care facilities will change that political calculation, because the public might demand change. Australia's federal control and funding of senior care stands as an example.