Mary Jean Hande and Christine Kelly advocate for a publicly funded home care service that is guided by the best practices and the experiences of the people on the frontlines of care, namely health care workers, patients, and their families.
Manitoba is undergoing a rapid transformation of health and social services. This includes the closure of emergency departments, the privatization of occupational and physiotherapy, and expansion of mixed-model home care. Many commentators characterize these changes as part of a privatization and austerity agenda that is shifting health care values in Manitoba. Mixed-model home care, in particular, is unlikely to advance social-justice informed approaches to public policy.
On September 20, 2017, Health Minister Kelvin Goertzen announced “Priority Home,” a mixed-model home care service set to launch this November. This service aims to provide intensive home care for up to 90 days in order to divert individuals from entering hospitals and residential care homes. This will allow older people to be assessed for entry into residential care at home, rather than undergoing this process in the hospital. It will also provide bridging support while applying for home care services. Currently, many aging people and their families do not initiate the home care application process until they are in crisis. Providing intensive ‘bridging’ at times of crisis, with the aim of avoiding more costly and institutionalized care, does indeed respond to urgent health care gaps.
However, the Winnipeg Regional Health Authority press release is vague about what Priority Home’s “mixed-model” approach will mean for care workers and broader commitments to universal health care. Two thirds of the $15.7 million budget will go towards private companies to provide these services. While receiving care at home at times of crisis is often preferable to institutionalization, there are legitimate concerns about private companies providing these services. Promises have been made that the public sector will re-absorb the “private transitional care beds,” however it is unclear how this will happen.
Evidence shows that privatized health care geared towards finding greater “efficiencies” and cost-savings, mean that social justice or social determinants of health approaches are further removed from care delivery. In these privatized models, clients/patients often have less access to individualized care alternatives, as they are guided instead towards the most cost-effective options. In a shocking example from residential care, a study in Ontario found that “for-profit facilities have significantly higher hospitalization and mortality rates than not-for-profit facilities.” This mixed-model “fix” erodes hard-earned public infrastructure, may exacerbate social inequalities, and could lead to extremely negative health outcomes.
Priority Home is proposed as “an intensive intermediary” until public infrastructure can reabsorb these services. This privatized “fix” to a crisis of Canadian health care is a familiar refrain. Simon Enoch and Christine Saulnier (2016), of the Canadian Centre for Policy of Alternatives, refer to a recent report from Privatization Nation, saying, “We thought this to be conclusive evidence that despite 30 years of experience governments rarely seem to get privatization right, and more often get it wrong with astonishing regularity.” Experts on public-private health care models, like Heather Whiteside at the University of Waterloo, argue that these temporary “fixes” rarely (if ever) live up to their promises. Given this track record, it’s hard to imagine how the public sector will simply re-absorb the “private transitional care beds.”
In many ways, policies and practices of care are a litmus test for how socially progressive a given society is. Disability activist Mia Mingus describes care as an essential part of valuing marginalized people who are often isolated in health care systems. Mingus urges us to nurture alliances among workers and those who use services to reveal the urgent politics of care. Donna Baines (2015) of the University of Sydney, says care can be part of an ethos of social justice that addresses poverty, class relations, sexism, heterosexism, ageism, and ableism. What does Priority Home say about the politics of care in Manitoba? It tells us that disabled and older people are considered a “burden” on the health care system, and that the “best” care is provided by the lowest bidder.
Manitoba Health reminds us that we have the “oldest comprehensive, province-wide universal [home care] service in Canada.” Amidst stories about “budget cuts,” “rising health care costs,” there is an opportunity to approach health care as a complex system, that is interrelated with other social services, and driven by a broader ethos of social justice. In a unique cross-sectoral example from the Netherlands, the Humanitas residential care home houses university students in exchange for spending time with older residents. Humanitas demonstrates a publicly-funded, intergenerational politics of care that enables flourishing of formal care workers, students and older people far beyond task-based understandings of care. Perhaps models like Humanitas can inform changes to the home care sector in Manitoba. Let’s use this juncture to develop publicly funded home care that is guided by the best research on the social, political and geographic dimensions of care and the experiences of the people on the frontlines of care—workers, clients/patients, and their families.
Mary Jean Hande is a Postdoctoral Fellow in Community Health Sciences at the University of Manitoba.
Christine Kelly is an Assistant Professor in Community Health Sciences at the University of Manitoba.