It used to be that if you didn’t feel well, you went to your doctor. If he thought you were seriously ill, he sent you to the hospital and you stayed there until you were better. When the Canada Health Act was passed in 1974, Canadians thought their health care costs were covered by our public system. Services provided by doctors and hospitals were accessible to all, regardless of ability to pay and if you were in hospital, all your medications were provided by the hospital as well.

We all know it is not that simple now. With modern medicine, better nutrition and improved lifestyle management (at least in industrialised countries), people are living longer. And with more accessible means of family planning, birth rates are going down. It’s population ageing and you hear about it, these days, almost every time you hear anything about our health care system. Often it is in the form of a lament: "how are we ever going to pay for all the care so many old people are going to need?"

Down-size hospitals and shift more and more care to the community. That’s been the first answer in Canada and in many other countries. The theory is that hospitals are expensive and community care is cheaper.

Here’s one way the shift to community care works out in practice in Ontario: reduction in acute-care hospital budgets, forces hospitals to send patients home sicker and quicker. These patients still need a lot of care, especially at first, and they can get that care at home through the Community Care Access Centres. But the Access Centres have strict limits on how many hours of care they may provide to any patient in a thirty-day period. They can, if necessary, bunch up those hours into the first few days a patient is home from the hospital. But that means a drastic drop in hours after those first days in order to stay within the monthly limits.

It is one or more members of the family who takes care of the patient when neither a nurse nor a personal support/homemaker is there. This is the main reason care at home seems "cheaper". Family members, primarily women, are not paid. Latest figures suggest that between 85 and 90% of all care provided in the home, is provided by unpaid family members, friends and neighbours.

Another way of shifting to community care in Ontario is to reduce the number of chronic care hospitals and transfer as many of their patients as possible into nursing homes. Nursing home beds are funded at less than half the rate from chronic care hospital beds. So, of course, this, too, seems cheaper. But nursing homes are not staffed to care for these much sicker patients and there are no more staffing ratios enforced by the province that could guarantee sufficient staff to meet their needs. Those residents who used to be the norm in nursing homes, who needed supportive care but were not completely helpless, are now left to pretty well fend for themselves, unless their families can come in to care for them or can afford to hire an attendant to stay with them.

The third aspect of shifting care to the community in Ontario is the decreasing availability of supportive care for the frail elderly, who could remain in their own homes with some support from the Community Care Access Centres. The funding for the Access Centres has never been enough to allow them to care for the very sick post-hospital patients plus provide supportive care for those with age-related or other disabilities, who need assistance with the activities of daily living. The Centres are under orders to care first for the sickest, a system of rationing that, combined with chronic under-funding, has left the frail elderly seriously under-serviced. There are now 11,000 persons in Ontario waiting for home care, and the hours for those who do receive supportive care have been drastically reduced.

Here, too, the family, if available, must pick up the slack. And they do, of course. Most families want to take care of their elder members, as they do their children, and are gratified to b able to do so. But they can’t always do it all. Most adult children, even if they live in the same town as their parents, belong to two-earner families who depend on these earnings. If they live far away, as so many do, they may not be available at all on a long-term basis. An elderly person who needs supportive help must have either available family or available money to purchase the needed care they are not getting from the public system. With neither family nor discretionary income, a person’s choice is to do without care and deteriorate rapidly or to look for a retirement home that can be paid for with very meagre resources

The government of Ontario is planning to introduce a new act governing both institutional and in-home care for the elderly, the chronically ill and the disabled. There is reason to fear that the new Act will not correct, but will rather perpetuate all the problems noted above.

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