Worrying breakdown in Ontario reforms
By David South
This Magazine (Canada), October-November, 1992
The Senior Citizens’ Consumer Alliance for Long-Term Care’s report on the Ontario New Democratic government’s health care reforms, released in July, documents what many people suspected: the much-needed reforms are mismanaged and dangerously close to chaos.
The report compares the present crisis to the failed attempt in the seventies to move psychiatric care out of institutions and into communities by closing 1,000 beds. Patients were left with inadequate community services, resulting in many homeless and jailed former patients. The alliance fears seniors – the biggest users of health services – could fall victim to reforms in the same way.
According to many health care reformers, Bob Rae’s government seems to have lost control of the issue, resulting in massive job losses and a worrying breakdown in services.
The NDP’s health care document “Goals and Strategic Priorities” reads like a wish list for progressive health care reformers, ranging from disease prevention programmes to improved access to health care for minorities, natives and women. To many, the debate isn’t over these goals but how they are achieved and what the government’s true motives are. Under pressure from big business and its lobby groups, the NDP is desperate to save money where it can, and as Ontario Health Minister Francis Lankin says, “not disrupt or destroy business confidence.”
Emily Phillips, president of the Registered Nurses’ Association of Ontario, is blunt: “The NDP’s plans sound good on paper, but they can’t give a budget or direct plan on how they hope to carry out reforms. They are going about things backward. They cut hospital beds and lay off staff without having community health care services ready.”
The national trend in health care is to deinstitutionalize and bring services to homes and communities. It is hoped that emphasizing prevention and healthy living will significantly reduce the need for hospitals, expensive drugs, surgery and high-tech equipment. The NDP has pledged to spend $647 million to reform long-term care services by 1997 – creating services that will allow seniors to stay in their own homes.
Problem is, the NDP has embarked on radical down-sizing of hospitals – closing beds and laying off thousands of health care workers – right now. Lankin claims that in the worst-case scenario, layoffs this year wouldn’t exceed 2,000, but the Ontario Hospital Association claims 14,000 jobs are in jeopardy. Phillips believes it will be hard to estimate job loss: “It is hard to even record the number of nursing jobs lost, because for every full-time job cut many part-time and relief positions go with it.”
Chaos will result when people who depend on hospitals have nowhere to turn but the inadequate community health care services, which are uneven and narrowly focussed. To make things worse, the same funding restrictions placed on hospitals have also hit the services that are supposed to save the day.
“I haven’t heard of any change in the quality of care. It is just too early,” says Phillips about the effect of layoffs on hospitals. “Right now the nurses are picking up the slack, but soon they will burn out. I don’t feel confident this government has the management skills to do this. I’d like to see a plan in place before moving people into the community.”
Training for laid-off hospital workers will have to come from the $160-million allocated for retraining workers laid off by cities, universities and school boards – all of whom are coping with record-low budget increases.
In February, Lankin appealed to hospitals to do everything in their power to make layoffs painless and to trim doctors and administrators first. But the NDP has yet to pass legislation that would bind hospital boards to make the right cuts. The boards operate at arm’s length from government and continue to make unnecessary decisions, ignoring the NDP’s moral pleas.
Rosanna Pellizzari, a member of the Medical Reform Group and chair of the Ontario Association of Health Centres, wants better community accountability for hospitals before they lay off staff and cut services: “Sometimes it makes sense to bring people to hospitals. Planning must be at the community level and open and democratic. Health care workers, who are mostly women, should not be scapegoated for financial problems. Doctors and management should go first. Physicians experience very little unemployment.”
Carol Kushner, co-author of the book Second Opinion, which evaluates the country’s medical system, sees chaos resulting from the conflicting agendas of governments and health care reformers: “Will the tremendous contradictions of institutions be transferred to the community? The federal government is rapidly draining money from medicare while provincial governments are having a hard time. This hasn’t produced extra funds for re-allocating services to the community – which was recommended by reformers. You have to ask: who is going to fall through the cracks?”
This Magazine (Canada), October-November, 1992.
Psychiatric care lacking for institutionalised seniors
By David South
Today’s Seniors (Canada), November 1992
“Don Weitz wears a T-shirt bluntly saying, “Fry rice - not brains.”
Seniors who live in nursing homes and homes for the aged are receiving an inadequate amount of psychiatric care, according to a study conducted by Toronto’s Baycrest Centre for Geriatric Care.
Dr. David Conn, director of psychiatry at Baycrest and an author of the report, says action must be taken to remedy this situation, since at least 80 per cent of elderly long-term care residents suffer from some form of mental disorder.
The issue of psychiatric care for seniors is complex. There are many, often strongly-held, opinions about the nature of this care and what measures will genuinely improve the mental well-being of seniors in institutions.
According to The Senior Citizens’ Consumer Alliance for Long-Care Reform, Ontario has the highest rate of institutionalisation of seniors in the world, with 7.5 per cent of seniors over the age of 65 and 15 per cent over 75 in institutions. The Alliance demanded in its reforms in Ontario that seniors’ mental health problems be taken more seriously and be included in any assessment for care.
Baycrest’s report surveyed 1,148 medical directors and nursing directors in over 500 nursing homes and homes for the aged across Ontario. The 601 who responded reported that 37 per cent of their residents received no psychiatric care, while only 12 per cent received more than five hours per month. The most common psychiatric problems under treatment were depression, agitation, wandering and physical aggression.
“Recognition of significant mental disorders in nursing homes is a recent phenomenon because geriatric psychiatry is a relatively new field,” says Dr. Conn. “The usual approach has been to reach for the prescription pad. We know now that antidepressants have been underused and tranquillizers overused.
“To deliver effective psychiatric care requires more than just psychiatrists - teams of psychiatric nurses can also be involved. Hopefully the staff of these institutions will become better educated as a result of this report.”
Dr. Kenneth Shulman, head of psychiatry at the Sunnybrook Health Sciences Centre, feels the worst neglect occurs in private rest homes.
“There is general lack of accountability when it comes to geriatric psychiatric services.” Schulman advocates a coordinated, comprehensive regional network of services.
Dr. Conn is sensitive to reports of sexual, physical and mental abuse of residents in some institutions. He says staff as well as residents of institutions can benefit from psychiatric consultations. “If more psychiatric consultants were available, the staff could also receive help in working out their problems,” he says. “Unfortunately the fee-for-service system doesn’t include paying for visiting staff.
“Being in an institution is not easy for anyone. It often means being apart from family, living with strangers, loss of freedom and having to live by the institution’s timetable.”
One of the most controversial of psychiatric treatments is electroconvulsive therapy (ECT). ECT involves placing electrodes on the sedated patient’s head and passing 100 to 175 volts of electricity into one of the lobes of the brain to induce grand mal seizure and coma.
Opponents of ECT say the procedure can cause memory loss and confusion, and in some cases proves fatal. A 1985 Ontario government task force report recommended against using ECT in certain cases: “For patients whose work requires a clear and precise memory, ECT is probably contraindicated.”
But many other sources say that while ECT has been abused in the past and, like many other medical procedures, may not be a pretty sight, it is sometimes effective in combating depression.
Dr. Conn confirms that the controversial procedure is still being used on seniors. “ECT is used on very depressed people,” he says. “It is a hospital-based service. The patient is admitted to a psychiatric unit of the hospital. We do it at Baycrest. It is only a last resort and has often been life-saving.”
Don Weitz, a senior citizen and spokesperson for Resistance Against Psychiatry, doesn’t mince words about what he says is the adverse effects of electroshock therapy and psychiatric practice in general. He wears a T-shirt bluntly saying, “Fry rice - not brains.”
“We have known about the adverse effects of shock for years,” says Weitz. “Research from the ‘40s and ‘50s was very clear that there was brain damage.
“What doctors mean by improvement is in fact post-injury euphoria - the brain will overcompensate with giddiness, and this only lasts for two to four weeks. Doctors seldom test people for more than two or three months afterwards.”
“What we know for sure is that within the institutions, they would rather give drugs or shock than talk to seniors. I think this should be called elder abuse - what else could it be? Is it such a mystery why people are depressed in institutions where they are abused? Psychiatrists have a vested interest in billing OHIP for pushing the button.”
But Dr. Shulman disagrees with blaming the atmosphere of institutions. “It is simplistic to think that the environment is responsible for aggressiveness or other problems,” he says. “These people are cognitively impaired - it could be medication-related or something else. These are complicated issues.”
For any nursing home workers who want further advice about psychiatry, Baycrest has produced a “Jargon-free” guide called Practical Psychiatry in the Nursing Home.
"Psychiatric care lacking for institutionalized seniors": Today's Seniors, November 1992
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