Nursing home sector needs basic reform not more money

Posted on July 22, 2008 in Child & Family Debates, Debates, Governance Debates, Health Debates – Opinion – Nursing home sector needs basic reform not more money: Social goal of caring for elderly entrusted to firms with incentive to cut costs, and corners
July 22, 2008. Ernie Lightman

Personally, I’m quite relieved the Ontario ombudsman won’t be able to investigate the many individual complaints about quality of care in the province’s nursing homes.

His mandate does not allow this.

And that’s a good thing.

What we do not need is another exposé of horror stories in nursing homes.

We already know that in many – perhaps most – cases, care provided is below any reasonable minimum standard. Just ask anyone who lives, has a relative or knows someone in one of these places.

Or look at newspaper archives to see what the Toronto Star and other media have unearthed over the past decade or so. It isn’t a happy story.

What we do not need are more micro-level case investigations. What is desperately required is a structural analysis of a system that fundamentally does not work.

With remarkable unanimity, providers – both for-profit and not-for-profit – unions, opposition parties, advocacy groups (including many in the media) and families all call for more money to be poured into the nursing home sector.

More money, they believe, means more staff and better services, so that everyone lives happily and in dignity.

I strongly dissent from this view. More money does not necessarily translate into better care: If it did, we’d be seeing marked improvements in outcomes from recent increased public spending in the sector, and these are not evident.

Putting more public money into nursing homes without other more fundamental reforms is just tossing the taxpayer’s hard-earned dollars down a bottomless pit.

The central problem is that nursing homes are institutions, as are jails and schools. And within institutions, some have power and others – in this case, the clients – do not. And those with power tend to abuse it. This is a universal truism.

The situation is exacerbated today because (unlike jails and schools) the majority of nursing homes in Ontario are run by large corporations whose goals are to maximize profits and to minimize costs.

They are not public services built on principles of altruism. We have entrusted social goals of caring to businesses who have every financial incentive to cut corners and thereby cut costs.

There is no more reason to trust the benevolence of the CEO of a for-profit nursing home than the CEO of a bank or oil company. The business of business is to maximize profit.

Were there competition in the world of nursing home providers we could perhaps rely on enlightened self-interest and market forces to produce quality outcomes for residents.

But there is no competition, so we have to regulate nursing homes to try to keep them honest, to minimize the opportunities for them to cheat. But for many reasons, regulation does not typically work: If it did, we wouldn’t be needing the ombudsman’s investigation today.

“Quality of care” itself cannot be directly measured by regulators, so instead we use a large number of indirect indicators. This creates the bureaucratic quagmire so hated by the operators.

But there is no alternative other than to trust the good faith of the corporation, an approach that does not work.

Government inspectors are human and fallible and they do not tend to inspect at 3 a.m., so that’s when the operators can stray, with relative impunity: They can leave the resident in a urine-stained bed because they are skimping on staff, or they can ignore the resident’s call bell. It’s easy to “water down the soup” without fear of detection.

Sanctions in nursing homes are hard to apply: Modest financial penalties are just another cost of doing business. If a home was shut down – its licence lifted – suddenly the province would have dozens of frail seniors out on the street with no one to care for them.

Arguably, Ontario has placed itself in a position where it needs the for-profit nursing home operators as much or perhaps more than they need the province: The balance of power has shifted from the regulator to the industry.

The solution to this dilemma does not lie within the nursing home sector, but outside, in the world of community-based home care. More home care, over time, means fewer people needing entry to nursing homes, more seniors living in familiar environments independently and in dignity.

Some people will always require levels of care that can only be provided in institutions. But there are many residents of nursing homes who would not need to be there, were adequate supports available in the community.

Home-care services in Ontario were drastically cut by the Harris-Eves-Flaherty Conservative government and funding has only been partially restored by the Liberals.

One day in a nursing home costs about $120 in public subsidy, a figure that would provide six hours of home care (at $20 per hour). Though few seniors in Ontario receive this, six hours’ support would provide substantial help with shopping, washing, cleaning and so on, a situation that would enable many to stay longer in their own homes, with a distinctly higher quality of life.

So the only real solution to the nursing home crisis is not to pump more money into a system where additional funding will likely translate into higher profits and better stock market performance.

Instead, we must – over time, but expeditiously – de-emphasize the nursing home sector and build up a credible and effective program of community-based in-home care. Forget about strengthening the nursing home which is, ultimately, yesterday’s solution to today’s and tomorrow’s problem.

The McGuinty government has acknowledged the need for a fundamental change of direction in this area, but its actions and its money do not keep pace.

The ombudsman could do us all a great favour were he to report that focusing on individual complaints, as he originally wanted to do, would merely study Band-Aids in a system that desperately needs fundamental structural reform.

Ernie Lightman is a professor of social policy at the University of Toronto. In 1991-92 he was a one-person commission of inquiry into assisted living in Ontario. He studied the nursing home model extensively in the course of his investigation.

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