Unveiling the Invisibility: Accountability in Long-Term Care Homes

Memories of the tragedy in Canada’s long-term care (LTC) homes from the pandemic are fading all too fast.  However, this tragedy was not an accident; it was the result of a series of deeper problems with the ways LTC is funded, managed and understood.  Without concerted action, these problems will continue to fester, and indeed grow with Canada’s aging population.

Addressing these problems requires actions on a number of fronts, from operating standards to staffing, to assuring the human rights of LTC home residents.  The most important actions form the core recommendations of a just-released report from the Royal Society of Canada (RSC).

One reason for the failures in Canada’s LTC homes is their general invisibility. It has only been the unnecessary spike in residents’ deaths from the pandemic that brought these to light.  With this tragic visibility, there has been a flurry of government actions. But as myriad experiences have taught us, as soon as the light fades, actions weaken.

One of the core recommendations of the recent RSC report is the creation of a robust “accountability framework,” in turn, based on strong data reporting.  This is not a new idea; the 2003 First Ministers Health Accord also spoke repeatedly about accountability. However, governments’ support for the underlying data waned over only two or three years, as did support for the short-lived Health Council of Canada a few years later.

In order to avoid yet another failure, we must understand what an accountability framework involves, and why it has failed in the past.

One fundamental reason for failures is the constitutional division of powers. The provinces and territories, with primary jurisdiction for healthcare, do not want to be “accountable” to the federal government, even though the federal government channels billions of Canadian taxpayer dollars to them. However, they should be accountable to their own populations.  

The only way Canadians can learn what works and what doesn’t from each region, no matter their differences, is if the data are comparable – this is a legitimate role for the federal
government.

Here we come to the reason for past failures: no provincial/territorial government wants to be shown to have poor performance in any area of its jurisdiction, certainly including healthcare.  In a phrase, “why shoot the messenger if instead you can prevent there ever being a messenger?”

In the face of such self-interested resistance, an obvious response is for the federal government to incent the needed standardized data generation across jurisdictions, and then assure these data flow in ways that can populate a well-designed accountability framework.

Such a framework should include key indicators, such as the levels of direct care staffing per resident on LTC homes, and the frequencies of falls leading to fractures and hospitalizations.  But the data flows must be much more than a handful of indicators. Analysts need to be able to drill down in the data to see, for example, what kinds of staffing levels and mixes are associated with the lowest rates of hospitalizations for falls, and other factors, including language and broader social determinants of health.

The federal government has ample constitutional powers to give effect to the needed data, not least from its spending powers and its power for “peace, order, and good government.”  

The federal government does appear to be going through the right motions here. The major cash transfers announced in 2023 to the provinces and territories include $500 million for data and assign the Canadian Institute for Health Information (CIHI) a
central role.

Yet in the 2017 First Ministers Health Accord, where billions of dollars were transferred from the federal government focusing on LTC and mental health and addiction, all governments agreed that CIHI should be given the mandate to develop relevant indicators.  Three years after the Accord, CIHI had published only one indicator relating to LTC, and it was based on hospital rather than LTC data.  

CIHI does the best it can, but it is seriously limited by the data provided to it by the provinces and territories. For example, data about LTC residents are not connected to staffing levels, hospitalizations and other kinds of healthcare utilization, nor to surveys of all those waiting to access homecare or LTC homes.

It is impossible for provincial/territorial residents to hold their governments accountable for their responsibilities in LTC if the data available are biased, and the most important kinds of data are completely absent.

We take for granted in other areas, such as GDP, unemployment and inflation, that there are ample underlying data enabling a dissection of the observed trends.  We deserve the same for LTC.

It’s long past time the federal government used all its constitutional powers. 

By Michael Wolfson

Michael Wolfson, PhD, is a former assistant chief statistician at Statistics Canada and co-author of the Royal Society of Canada report, Repair and Recovery in Long-term Care.