Evidence-based policy, wouldn’t that be a change. The case for personal care homes

A version of this article was first published in the Winnipeg Free Press June 8, 2016.

By Pete Hudson

Budget 2016 pledges $160 million to create 1,200 new Personal Home Care (PCH) spaces. It is to be hoped that this laudable move will be implemented based on the evidence. Regrettably this is a practice woefully lacking.

There is, for example, a consensus of experts in the field that long term care is a continuum. The Manitoba Centre for Health Policy (MCHP) study reported in the Free Press yesterday makes exactly that case. It found that an expanded Supportive Housing Program could meet some of the predicted increased need, thereby reducing the need for more PCH beds. An identical argument was made in a 2012 MCHP study which included the Home Care Program The combination of the two programs has already reduced the admission rate to PCHs. In short, the new government should avoid favouring one part of the system at the expense of others.

The area in which evidence is most often dismissed is in the area of ownership of which there are three types – private for-profit, private non-profit and government. The past twenty years has seen a significant increase in for-profit ownership in most provinces in the face of overwhelming evidence that it delivers poorer quality service. One well-accepted indicator of quality is the rate of hospitalization and mortality. A recent study of Ontario PCHs found that the rate of hospitalizations and death rates of residents in for-profit homes was much higher than in non-profit homes. In Manitoba, as far back as 1995 higher rates of hospitalization were found in the for-profit homes. A more recent Manitoba study estimated that residents of for-profit PHCs have about a 70 percent greater odds of dying in an acute care hospital than residents in non-profit PHCs.

Other indicators of quality of service are such things as the volume of complaints recorded, the incidence of critical events such as falls, violence toward staff, all of which have been found to be most prevalent in for-profit homes. These, along with hospitalization and mortality rates have all been attributed largely to staffing quality and levels. Once again the for-profit sector does not compare favourably with the non-profit sector, although all have been found wanting to some extent. Manitoba has only guidelines on staffing levels at provincially- funded homes. Even these are seen to be too low and in any event do not have the force of law. One practice which subverts the guidelines is “working short” which is when a PCH fails to cover for vacation and sick time of staff, so that guidelines are apparently met but there is a shortfall between paid work and actual hours worked. The for-profit sector appears to use this subterfuge more often than the non-profits as well as paying staff lower wages along with fewer benefits. Another is the heavier reliance on aides rather than fully qualified nursing staff as well as greater use of casual contracted labour. The latter practice tends towards less skilled staff as well as staff who have no relationship with the residents – a factor important to the wellbeing of the residents.

The issue of cost is much more difficult to ascertain. This is because one of the problems with the delivery model whereby the public purse subsidises or contracts for services delivered by the for-profit sector is its lack of transparency. In Manitoba and elsewhere PCH agreements are made between public and the private around capital and operating costs, per diems etc. all of which are different and not subject to public scrutiny. One major international study which included Canada found that administrative costs were much higher in the for-profit sector and that profits were very high in some instances making it difficult to believe that for-profit ownership is the more cost effective model either for the public purse or for the residents.

During the 2016 election campaign Brian Pallister cited the Niverville private non-profit PCH as a desirable model, but he should be careful of over-reliance on uncertain charity to provide a cheap service. That sector has become increasingly stretched over the years and donor fatigue is setting in. It is also difficult to see how this approach could be fast tracked. However, there are certainly worse ways to go as we have seen. In that regard it is speculated that the increase in for-profit involvement in PCH operation is a result of an ideology which accepts the superiority of the for-profit sector over the public sector despite a great deal of evidence to the contrary – certainly in the case of PCHs. We hope that Premier Pallister will not go that route and that in a post election interview, his statement that perhaps the private sector can help with the proposed increase in PHC beds, doesn’t mean that he too will ignore the cautionary evidence. Reporting rarely distinguishes between the three types of ownership, but the government owned mode seems to still be the largest of the three in Manitoba. Why is that option now off the radar?

The elephant in the room of course, is massive tax cuts by the two senior levels of government in the last 20 years amounting to hundreds of billions of dollars, largely benefitting the more affluent. Without them, this penny pinching reliance on charity or cheap labour to care for our elderly and infirm would not be happening.

Pete Hudson is a Senior Scholar in the Faculty of Social Work, University of Manitoba, and a CCPA MB Research Associate