The enormous pressure on this sector is the result of the provincial government's moves to close hospitals, cut beds, staff and funding and shorten the length of time patients are permitted to stay in hospital. As patients are pushed out of hospital too quick and sick, they are confronted with the grim reality of insufficient hours and services available to help them.

Access to this range of services is restricted either by user fees or means tests. Unlike hospital care, few home services are governed by the Canada Health Act.

It is important to note that this new version of Home Care is much more intense and bears little resemblance to the past. It is truly a new concept -  an acute-care hospital in the home, but without adequate funding and monitoring.

The CCACs, which become operational in 1997, are not-for-profit corporations governed by boards of directors. Membership in a CCAC is open to all residents in the community it serves. CCACs arrange for homemaking and professional services for eligible people in the communities they serve and for admission into long term care facilities. CCACs contract for these services with both profit and not-for-profit providers.

In addition to the CCACs, community support organizations such as Meals on Wheels, Friendly Visiting, etc., which operate primarily with volunteer workers are funded by the Ministry outside of the CCAC budgets. Adult Day programs are also funded outside the CCAC budgets, but accessed through the CCAC's.

The Long-Term Care Act is intended to govern long-term community services. Most of the Act's provisions were proclaimed into law in March 1995. The Act has still not been implemented because the necessary regulations have not yet been made. In the interim, the Ministry relies on predecessor legislation, which has not yet been repealed, and the service agreements it negotiates with CCACs and community support service agencies.¹

The Provincial Auditor raised concerns about the funding formula itself and said that the formula "does not ensure that funds will be used efficiently, give any assurance about the quality of care provided or establish the amount of funding required to provide an adequate level of service. Even if the funding formula did accurately reflect the need for long-term care community services in the 1994/95 fiscal year, it would need to be adjusted in subsequent years to reflect changes in demographics and changes in patterns of use."

The Auditor's recommendation:  "To better ensure equitable funding and access to long-term care community services, the Ministry should ensure that its funding formula takes into account service needs, ongoing demographic changes and changes in the health care system."

So high a proportion of the CCACs resources are required to meet the needs of post-hospital patients they are being forced to cut down on personal care/homemaking for chronic cases.

For example, the Kingston Community Care Access Centre board went public last September and announced that in order to meet its projected budget deficit, it would have to cut homemaking services for up to 2000 local people.⁴ 

The Brant CCAC declared that individuals undergoing elective surgery are not eligible for homemaking services! Brant has also reduced its maximum level of home support services from 60-40 hours/month and has declared that cleaning is not a service covered by the CCAC.⁵

The North York CCAC requested additional base funding to keep pace with demand. Instead of granting the request the Health Ministry told the CCAC that "waiting lists for people with non-urgent needs are acceptable." We vehemently disagree with this . People with crippling arthritis and osteoporosis, those who have been incapacitated by strokes or have not yet fully recovered and other "non urgent" cases cannot wait for vital assistance and care; yet , they are being forced to.⁶

The underfunding of in-home services is forcing providers to ration the services for which no fees are charged. When clients point out that they are not getting sufficient services they are told that they can "top up" the services for a fee. Non-profit community agencies sometimes charge on a sliding scale (depending on income) for these "top-up" services, but that is not the case with for-profit service providers.

This is the first documented evidence we have seen confirming a formal reliance on the unpaid labour of relatives and friends. This is a frightening substitute for a trained and adequately-paid workforce A government that gives virtually no financial support to children who leave paid employment to care for aging parents, to women who are the new class of involuntary recruits and to the many other substitute caregivers has no right to coerce them into caregiving, but this is already happening. For example, the Brant CCAC guidelines state that "Individuals who have a capable caregiver are not eligible for home support services. This includes caregivers who work outside the home."⁸

This document is a warning that the government's view of in-home care is not one that will meet the social need.

The thrust of the government's intention is clearly to increase the privatization of in-home care and force non-profit organizations to lower their standards (if they want to be competitive) of wages, conditions and training for those who actually provide the care. Workers are threatened with deteriorating working conditions and pay. Clients, too, pay the price when overworked, underpaid and untrained workers are sent to care for them.

The Tories appear not to care what happens in this sector. For example, the Provincial Auditor found that the government had not developed standardized tools for CCACs to use to assess whether quality of service requirements in the Request for Proposal process were even being met. As more contracts are offloaded to the private sector, this becomes vitally important. The Auditor recommended that the Ministry develop these tools.

Monitoring and quality control are not high on the government's list of priorities. But the Provincial Auditor had a lot to say about these issues. Here are some of the highlights:

 The Ministry does not have adequate procedures in place to measure and report the effectiveness of community based services and to ensure complaints are properly investigated.

 The Long Term Care Act permits the Minister to appoint program supervisors to inspect premises where a long-term care community service is provided on the premises. Inspections are an important means of assessing the quality of care provided and determining whether provincial legislation and standards are being complied with. The Auditor found that the ministry was not conducting inspections of long-term care community service agencies and had not developed procedures for conducting inspections.

 The Long-Term Care Act requires CCACs and other long term care community service agencies to establish a formal process for receiving and reviewing complaints from service recipients. In addition, a person receiving long term care community services has the right to be informed in writing of the procedures for initiating complaints about a community service agency. The Auditor noted that regional offices had not requested statistical information on the number and type of complaints received or the timeliness of follow-ups. Information on complaints received could corroborate other evidence of service quality deficiencies and could assist in identifying areas for further investigation.

Complaints may also be made directly to the ministry. Regional staff are required to review and investigate complaints, and where applicable, intervene on behalf of service recipients. But even there, the Auditor noted that the process for recording and following up complaints was inconsistent and that regional offices did not have a system to record the receipt, status and details of complaints.