Warren Buffett has a quote he uses to remind investors that companies can look promising on the face of it, but their warts (and worse) can reveal themselves pretty fast when circumstances change. Investor beware.
You’ve got to admit that’s a potent image! Buffett’s quote applies equally well to our social structures, which can seem adequate to their purpose … until a global pandemic hits. Then watch out for all those naked swimmers!
One of the many naked swimmers, aka societal issues, that has been revealed during this COVID pandemic is the scandalous number of deaths in nursing homes and the accompanying revelations of just how inadequately supported residents of many of our long term care homes are – in virtually every ‘wealthy’ country. I am ashamed to say that Canada leads the way in percentage of deaths in long term care homes, by far. A full 81% of our country’s COVID-19 deaths have been in our nursing homes. Other countries vary from a low of 10% in Hungary to 42% in the U.S. to 66% in Spain. The average among 17 ‘developed’ countries stands at 42%. That’s a lot of deaths in seniors’ homes, however you look at it.
Before we look at typical models of how these homes are run, let me remind you of the fact that there is a tsunami of challenges about to hit the long term care (LTC) sector, with or without pandemics. In many parts of the world, including Canada, there already are not enough beds for seniors (and others with chronic debilitating illnesses) in LTC facilities, so they are ‘warehoused’ in hospital beds. This is a lose-lose situation all around, since hospital beds are more expensive for governments than LTC spaces, and having the beds taken up by people who do not actually need hospital care means that the hospital can accept fewer patients than it otherwise could. A totally unacceptable state of affairs.
Now let’s put another factor into the mix. Our societies do not have so many more elderly people than we have LTC spaces for because of the Baby Boom; the baby boomers haven’t reached that stage yet. I happen to be an expert on that subject because I was born in the first month of the first year of the Baby Boom – 1946. Same year as (gulp) Donald Trump, George W, Bill Clinton, Sylvester Stallone, Dolly Parton, Sally Field, Liza Minelli, Cher, and many other well-known folks; all vital, none ready for nursing homes. We got the Baby Boom started (well, actually, our parents did) and we boomers continued to be born through 1964, nearly twenty years. So the truly frightening pressure on nursing homes due to the baby boomers is a ways off, but closing in fast and guaranteed to last a long, long time.
The reason that the nursing homes are already overflowing is because, thanks to medical research and health officials that some political leaders are ignoring at their own peril, we are living longer. In fact we’re living a lot longer. Just to give you a taste of how things have changed, I’ve chosen a few countries to illustrate the point. This table shows life expectancy for ranges of years, averaging the expectancy for men and women. Instead of most of us dying off in our late 60s, we’re lasting into our 80s and some well beyond.
The bottom line is that in nearly every ‘wealthy’ country our nursing home capacity is insufficient for present needs, and the demand that is just around the corner is going to bring LTC systems to their knees everywhere.
That’s just the capacity issue. That doesn’t address why those who were in care during this pandemic were decimated by the virus. That has to do with antiquated floor plans, inadequate levels of staffing, inadequate support for the inadequate numbers of staff, and lack of oversight and accountability. All of this has to do with – you got it – money. If people are able to afford high-end private LTCs, then these issues are not likely to arise. Those residences are typically new, with private rooms and bathrooms for each person, and the level of care staff one would expect from paying the big bucks. But for the large percentage of the population who are in private, non-profit, or public care homes at more ‘affordable’ prices, the residents are likely to have roommates, shared bathrooms, crowded public spaces, and inadequate numbers of poorly paid caregivers. The reality is that this sector is already a financial albatross for most governments, and until now they have chosen to turn as blind an eye as possible because they just couldn’t imagine where the money would come from to do it right.
In most countries, including Canada, the private homes at this level get their money from the governments responsible for Social Services. Just as hospitals contract out food services and cleaning to private companies to try to save money, when those workers used to be employees of the hospitals, the governments responsible will contract out the running of care homes in the hopes of containing costs. Any of us who have been involved in RFPs and contract negotiations for such services know that you get what you pay for. Nothing more, maybe less. You convince yourself that you’ve shifted the responsibility to the private contractor, but, sorry, you are still responsible. Quality is scrimped as far as possible to match a contracted budget that will still allow for shareholders to get their payouts. This contracting-out model needs to be looked at very carefully.
In Canada’s situation, our two biggest (by far) provinces, Ontario and Quebec, made what turned out to be very poor decisions when faced with how to free up hospital beds for the expected wave of COVID patients, albeit with the best of intentions. They moved all the people in the hospitals who didn’t really require hospital care and were waiting for a bed in a provincial care home to whatever space could be made for them, at whatever care home. These decisions were made in order to free up beds for the critical COVID patients that were anticipated – but these vulnerable people were sent out into a system that was barely coping to care for the residents they already had. And don’t forget that everyone was scrambling for PPE and testing, from hospitals on down, with demand high and supplies scarce, all fighting an unknown enemy.
Everything in the system was geared up to fail in a situation like a pandemic. Roommates shared their space and their bathrooms, as is the case in most older LTC homes (just as it is the case with older university residences). There weren’t sufficient resources, or understanding, for caregivers to be given PPE or specialized training. Because most of the caregivers are among the lowest paid workers, including the invaluable cleaning staff, they kept coming to work when they were sick, both because they needed the money and because they knew that their residents needed them. Because the care homes were insufficiently staffed, often care workers worked between two different LTCs, thereby inadvertently spreading the virus even further. If there was anything that could have gone wrong, it did. It was a disaster waiting to happen. It wasn’t too different in other countries.
The big difference going forward is that, thanks to the wake-up call from the pandemic, governments can no longer turn a blind eye to the current unacceptable situation and, even more so, the vastly increased need for capacity and accountability that is looming on the horizon. Healthcare is already a huge expense for every government that has responsibility for their universal healthcare. And we all agree that there is nothing more important. Well, ensuring our most vulnerable seniors are cared for in their final time of need falls in the same category, like quality education for our youth. Tough decisions for governments, for sure, but that’s what they’re there for.
The same governments, strapped for cash as they are, are going to have to ensure that nursing homes are moved way up their priority list. The day of reckoning has arrived. They need to consult with the public and with experts as to the best models for structuring nursing homes for the next generation. They need to take into account lessons learned this year so that new plans mitigate those frightening cracks that made it so difficult to protect residents and staff from the virus. They need to ensure that new building and staffing requirements keep the residents’ ongoing quality of life in mind, not just their physical safety. It’s important that there are opportunities for socializing and stimulation, not just more warehousing. Governments must have solid and reliable accountability measures in place to make sure that these principles are maintained. They need to determine what the relationship should be between healthcare and long term care. And, finally, they need to accept the fact that the caregivers putting their heart and soul into keeping your parents – or you – safe, clean, and fed, and providing a caring environment – are paid a respectable wage, with benefits. How could we accept less?