In an interview with the independent commission into the COVID-19 crisis in Ontario's long-term care homes, the minister responsible for those homes said she doesn't know why the sector has such a high prevalence of part-time work but suggested it is the workers' choice.
That's despite research from her own ministry that found part-time staff in the sector are seeking full-time work.
The commission has also heard considerable evidence that part-time staffing contributed to overall staffing shortages that left residents with inadequate care and shortcomings in the infection prevention and control practices necessary to keep the virus at bay.
Minister Merrilee Fullerton and her deputy minister, Richard Steele, were interviewed by the commission on Friday, the last of three high-profile interviews with leaders of Ontario's COVID-19 response. She was preceded by Chief Medical Officer of Health Dr. David Williams and Deputy Premier and Health Minister Christine Elliott, along with her deputy.
While Fullerton said she did not know why there is such a high prevalence of part-time work in long-term care, she suggested personal support workers may request it.
"It may be that some PSWs want certain hours during the day to accommodate schoolchildren," she said. "They only want mornings but they can't get all the mornings in one location."
She also said there may be a higher demand for part-time work in the future.
"I think with an aging population I think we also have to understand that there may be more demand for part-time work; and to create the flexibility for people at the ends of the spectrum; so whether they're in their early — perhaps having a family or whether they're at the other end of the spectrum and have — want a slightly lighter number of hours," said Fullerton.
However, the commission's counsel, John Callaghan, cited the ministry's recent study into staffing in the sector, and asked if Fullerton appreciates that it found that "sizable amount [of the part-time workforce] wanted full-time work?"
"Agreed. Understood," Fullerton replied.
The commission also noted that there is high turnover in the part-time workforce and the recruiting and retention of workers is one of the biggest challenges facing the sector. It noted the SARS commission had recommended that health-care workers minimize the number of workplaces to avoid spreading disease and cited a subsequent report that found the "casualization" of work in long-term care specifically presented a risk.
Another document the commission recently received was created by Fullerton's ministry in July, summarizing the lessons learned from the first wave. One clearly indicated that offering full-time hours both helped stabilize their staffing, but came at an additional cost: "Some homes offered full-time contracts for three months, which stabilized staffing. However current funding isn’t enough to allow them to continue to do so."
Another lesson was that money is a motivator — staff left for jobs where they could be paid more.
Vivian Stamatopoulos, a long-term care advocate and professor at Ontario Tech University, said part-time, casual work is a cost-saving measure that's most prevalent in for-profit homes.
"If Minister Fullerton spent time visiting LTC homes or reviewed the considerable and long-standing research in the area, she would understand why there is so much part-time, casual work in LTC," she said. "Frankly, her testimony comments on this matter further underscore why so many calls have come in for her resignation."
Staffing was a major focus of the interview. The commission questioned Fullerton and Steele extensively on the time it took the government to order that staff only work at one long-term care home, to avoid spreading the disease between homes. The order took effect on April 22, 2020.
The vast majority of infections in the first wave had already occurred by then, according to the commission, which noted that the large chain Revera had found 97 per cent of its first-wave infections had already been contracted.
Fullerton and Steele attributed the delay, for the most part, to fears that the measure would further destabilize staffing, which they said came to pass. Fullerton said the single-site order contributed to homes suffering a staffing collapse, which is why the Canadian military and hospitals were required to be sent in to assist.
The commission noted that Ontario will need to recruit enough workers to staff long-term care homes, once it has built 15,000 additional beds, and meet its goal of increasing staffing levels to an average of four hours of care a day per resident.
Callaghan and Commissioner Frank Marrocco questioned Fullerton on the role of profit in the long-term care system.
While all long-term care homes have the same funding model, regardless of ownership model, Callaghan summed up evidence showing municipal homes tend to spend significantly more on resident care. They are generally heavily subsidized by local governments — with York Region spending more on its long-term care homes than the provincial government, and Toronto spending an estimated $20,000 per resident per year. That allows York Region, for instance, to have fresh fruit and vegetables for residents, Callaghan said.
For-profit, on the other hand, can extract profits from one of the funding envelopes.
"So what I'm asking, Minister, if I'm a resident in York Region and it comes my turn and I end up in a for-private (sic) home, or I end up at York Region, why should that differential of care cost come about? What — how is that equitable?" asked Callaghan.
Fullerton said it's an "important question" but left Steele to answer in detail, and the civil servant didn't address the question of equity.
Marrocco put it this way: "The concern is one group is contributing in money and the other is taking money out."
Callaghan followed up by asking if the fact that municipalities feel compelled to subsidize the homes to such an extent is a sign that "we [are] undervaluing and underservicing our long-term care residents through the provincial amount."
Fullerton initially answered by saying some homes can benefit from economies of scale — but Callaghan noted that municipal homes are larger and can benefit from that, so that wouldn't explain why they'd need more funding. Steele noted that their staff tend to be paid more — and that may have been to their benefit in COVID-19.
Overall, Fullerton suggested the for-profit model will be part of the future of long-term care. Asked why Ontario allows real estate investment trusts to own long-term and contract out care to for-profit care companies, she replied, "That is something that, you know, historically has evolved. But if we're looking forward the magnitude of the problem that we're facing with an aging population it's not going to be one solution, it's going to be many solutions."
The commission focused on another area they are likely to include in their final report. Callaghan asked about the province's shortage of inspectors, which they noted left some homes without inspections after experiencing multiple outbreaks. He also said an assessment had flagged Sunnycrest Nursing Home in Whitby as high risk after the first wave, but no inspectors visited it before it experienced a devastating outbreak in the second wave, in which 34 residents died.
At times, Fullerton's comments seemed to put her at odds with other parts of her government. The government had been criticized for being slow to allow essential caregivers access to their loved ones in long-term care. Fullerton told the commission that was not her choice but was rooted in the concerns of the chief medical officer of health.
The commission also drew a distinction between her and Williams over the issue of asymptomatic spread. Callaghan highlighted one of her notes, showing she was concerned about it as of Feb. 5, and she told the commission she believed it was "a major issue."
By contrast, Williams told the commission he didn't accept it until later in the summer and spoke about his reservations about it to this day, something it was swiftly criticized for by outside experts last week.
“You were ahead of the chief medical officer of health in many respects, from your notes anyway,” remarked Callaghan.
The commission also highlighted a section of her notes from March 12, in which she indicated she refused to say in a video on the coronavirus that the risk was low.
“I was very concerned about doing a video that would show or tell people that the risk was low, even though that was what health experts and the health leaders in Canada were saying,” she said.
Fullerton also cited problems with the province's broader health response to COVID as reasons for failures in long-term care.
The commission, as well as outside experts in long-term care, had called for months for the province to come up with a plan to "decant" overcrowded long-term care homes — to move out residents who were sick or exposed, or conversely, those who remained well, to free up space to allow for proper care and infection prevention control. Fullerton told the commission she was also a proponent of the idea and had suggested it in early April but the health-care system didn't have sufficient capacity, particularly in terms of staff, to accomplish it. Another barrier, she said, was testing turnaround times were too slow to identify which residents were COVID-positive swiftly enough for the strategy to be effective.
The minister also attributed the high number of LTC deaths in the second wave to the high levels of community transmission in the province.
The interview concluded with Callaghan reading Fullerton a series of devastating quotes from the commission's interviews.
"Our elderly people shouldn't be treated this way," read the first. "If I had an animal that was treated like that I would be charged with animal cruelty. There is no excuse for it [...] And I feel bad that I even had to put my mother in there, but I didn't have a choice, and I didn't have a choice of homes either."
The next called long-term care's problems systemic: "And no one government is to blame totally; they're all in on it. They're all culpable."
Callaghan said he hoped Fullerton takes what the commission heard to heart.
"Absolutely and I — it's — this era has been such an emotional time," Fullerton replied. "It has been an emotional time for so many people, and I'm sure it's been emotional for all of you at times. And we have to come out of this stronger. People's lives cannot be lost in vain. And there will be good things that must come from this."
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