Hard Wages: Why Workers Don't StayGO TO MONDAY, MARCH 29, 1999
A Homemaker's Weekend
Wide-Open Competition Saves Money, but Draws Fire
Photo Essay by Fred Lum
Cheryl Allen looks after people's grandmothers, their spouses, their children, helping them with some of their most basic and intimate needs.
To many clients, the 43-year-old homemaker is like family, having cared for some of them almost daily for eight years.
Ms. Allen is driven and dedicated, working an average of 52 hours a week and logging more than 30,000 kilometers annually on her rounds in and around Fredericton.
Yet her T4 slip for last year showed her gross earnings were $12,891.35.
"Frankly, I could make more money on welfare, but I want some dignity in my life," Ms. Allen says. "I know I'm good at my job, and I take pride in my work, but when I look at my paycheque, I wonder: 'Why doesn't society take pride in what I do?' "
By some estimates, one in two Canadians of working age will be caring for a loved one at home within the next generation, and many of them will need help from homemakers. So virtually every baby boomer has a host of reasons for finding an answer to Cheryl Allen's question.
On the surface, the plight of homemakers is simply that of all low-wage earners. But in a rapidly aging society, it has potentially profound implications.
Homecare's attraction for clients is that it allows them a quality of life and freedom that they would not get in hospitals or nursing homes. But what happens if agencies can no longer recruit people to work under existing conditions? It is one thing to have a shortage of clerks at Wal-Mart; it is quite another to tell an elderly person with dementia or a quadriplegic that there is no one to assist them with their activities of daily living.
For governments, the lure of homecare is that it is far cheaper than keeping patients in institutions. But the burden of these savings has landed on the backs of workers, in particular homemakers, who provide about 80 per cent of community services. If wages rise, homecare costs will soar, and many of the savings from hospital closings will be lost. And if services are provided to all those in need, will taxpayers be willing to sustain the system?
New Brunswick has gone as far as any province in shifting care from hospitals to the community. In doing so, it has knocked down not only walls but wages. As with other cost-saving initiatives, this approach is almost certain to spread to other provinces, along with its repercussions of staff shortages and potential labour strife.
Homemakers do grueling, lonely work, with lots of travel and lifting and an increasing need for specialized, quasi-medical skills.
Patricia Burgess, a manager at the Fredericton Red Cross, which employs Ms. Allen, said the poor pay and work conditions create an unending nightmare for agencies in recruiting staff. "These girls are the working poor. They don't make much more money than at McDonald's, but over there the hours are steady."
So it's no surprise to learn that some agencies lose half their workers in a year, usually to institutions that pay almost twice as much, offer regular shifts and provide benefits such as sick time and overtime pay.
Like many provinces in Eastern Canada, New Brunswick contracts out home-support services. In the West, save in Alberta, workers in both the community and hospital sector tend to be unionized; in B.C., homemakers can earn up to $15 an hour.
For a time, New Brunswick negotiated contracts individually with agencies, but in 1996, aiming to cut costs, it accepted bids at only one rate: $9.50 an hour.
That's what it pays homecare agencies, non-profit and for-profit alike, for providing home-support workers to clients who need long-term help with daily living and can't afford to pay for it. (Individuals purchasing homemaking services on the open market pay $11 to $16 an hour.)
Out of the $9.50, agencies must pay all overhead costs -- administration, training, rent, utilities -- as well as wages. The amount that ends up with the homemakers at the Fredericton Red Cross, one of the best-paying agencies in New Brunswick, ranges from $6.96 to $7.49 an hour. Elsewhere, particularly in rural areas, homemakers get as little as the province's minimum wage of $5.50.
There is no overtime pay (except for statutory holidays) regardless of hours worked, no vacation, no health benefits, no sick leave, no pension plan and virtually no travel allowance.
Ms. Allen, for example, lost one month's pay last year when she fell seriously ill because of her exhausting schedule. A few more weeks flew out the window when her 1987 Honda Civic went in for repairs, including a two-week stint after a wheel fell off, an accident that almost took her life. Back injuries and falls are commonplace for homecare workers.
Because most clients need help with essentials such as eating, getting in and out of bed and using the toilet, there is no such thing as a day off for workers. Many tasks must be done at specific times, and assignments can be as short as one hour, so it is not unusual for seven paid hours to be spread over a 14-hour period. If a client goes on holidays, enters hospital or dies, the worker loses the hours. Those realities probably added up to a couple of more weeks of lost pay for Ms. Allen last year.
"The problem is I can't tell the landlord or the bill collectors that I just lost a week's pay because of something beyond my control. That's why I work the crazy hours -- I have to do it to survive, but I barely make it from paycheque to paycheque."
Along with its capping of homecare fees, New Brunswick has, for all intents and purposes, shifted long-term-care patients from the medical system to the social-welfare system. The result is two-tier homecare.
People who are deemed to need less than three months of medical care -- most post-acute cases -- still can get nursing in the home, and the cost is covered. But those who need help with daily living are assigned to the long-term-care program, with no medical care -- and if they don't qualify for government assistance, they must pay.
Clients in the publicly funded system are limited to $2,040 in services a month, and are charged a portion of their income (varying with their family situation) and 10 per cent of their assets annually.
"This is not health care, it's social support," said Gina Atkinson, program consul-tant with the support and maintenance program of the New Brunswick Department of Health and Community Services. "There is a lot of confusion out there about the role of government in the area. But homemaking services, in this province at least, are private enterprise."
It's tough talk, but the government defends the spending restrictions and the low wages imposed on homecare workers as a necessary evil. "We were a leader when homecare first started. We had high ideals, but they were costly ideals," Ms. Atkinson said. "The one snag we hit was financial sustainability, so we had to be more realistic about what we could provide if we wanted to maintain our excellent homecare system."
The result is a situation that pleases neither workers nor employers.
"We have to look seriously at continuing in a business that is a money loser," said Shirley Clayton, Eastern Canadian regional manager at Comcare Canada Ltd., one of the country's biggest private health-care companies. "If I'm going to pay these wages and still lose 35 cents an hour, why would I want more business?"
Comcare pays $6 to $6.50 an hour but, unlike most other agencies, offers health benefits to full-time employees. This is attractive because a disproportionate number of homemakers are single mothers.
The principal reason the company continues to offer home support is that it is complementary to many of its moneymaking services, such as nursing. But Ms. Clayton said it is becoming so costly and difficult to train and retain workers that she wonders whether any agency will be able to do it for much longer.
Turnover of staff in low-wage provinces exceeds 50 per cent annually. That is expensive for employers operating on a shoestring and a major source of irritation for clients, who demand not only quality but also continuity of care.
As well, the New Brunswick government's insistence in its contracts on a minimum of 210 hours training for workers makes it difficult to attract newcomers. Virtually no one will invest hundreds of dollars and a few months time to get a certificate that lets them apply for a job at scarcely more than minimum wage.
"It's a vicious circle: Everybody wants the best-trained workers, but training them is a losing proposition," Ms. Clayton said. And the cap on government reimbursement means the best workers cannot be adequately rewarded. With rare exceptions, once they have a little experience they land better-paying jobs in institutions. In New Brunswick's hospitals and nursing homes, attendants are paid $12.40 to $12.79 an hour.
Some observers see a tragic irony in the plight of New Brunswick's homecare workers: A system designed to improve the quality of life of clients in their homes has done so in large part by treating workers so miserably.
Janice Keefe, an associate professor of gerontology at Mount Saint Vincent University in Halifax, also sees in it a message about how policymakers take women for granted. "Across the board, homemakers are terribly undervalued and horribly underpaid," she said. "It's a striking manifestation of the way society undervalues women's work."
Virtually all paid care providers are women. By some accounts, three-quarters of unpaid family caregivers are women. And two-thirds of those receiving care in the home are elderly women, a slice of society in which staggering poverty is commonplace.
In other words, homecare is a service provided largely by women for women, many of them poor and politically voiceless. The caregivers toil stoically behind closed doors.
"It's part of women's socialization to do the caring and nurturing in families and to not complain about it," Prof. Keefe said. "But what we see is formal workers being treated as an extension of that, this unstated expectation that they should do this work for nothing -- or next to nothing."
There is a parallel between the plight of homemakers today and that of nurses in the 1960s. The virtually all-female profession, after so long being taken for granted, organized and unionized. Nurses became a force within the health-care system. Today, they are fighting the battle all over again, albeit on a much smaller scale, to have community nursing recognized.
Noreen Richard, director of professional practices and health policy for the New Brunswick Nurses Association, said salaries are not appreciably different in the homecare and hospital sectors. What concerns nurses is the absence of standards and monitoring of care in the home, and the cost-driven policy of having homemakers perform increasingly complex tasks.
Ms. Richard said the fact that there are no nurses in the long-term-care program is a worrisome trend, particularly for seniors who intend to remain in the community.
"Five years ago, homemakers were looking after homes. Now they're doing all the personal care. What will they be asked to do next? There are tasks where nurses should be present and they are not."
It is no coincidence that five years ago there were plenty of homemakers. Now, in many provinces, home-support workers are being recruited from developing countries, largely by agencies that used to deal exclusively with nannies.
Those who remain homemakers are growing tired of their lot. Earlier this year, more than 74,000 homecare workers in Los Angeles County unionized, a move The New York Times called the biggest breakthrough in labour organizing in more than half a century. Buoyed by that success, unions are expected to aggressively recruit low-wage workers in Canada, with homemakers a priority.
So far, unionization of homecare workers has been a mixed blessing. In B.C., widespread organizing led to huge wage increases, but to keep costs down the government tightened up eligibility criteria for homecare clients, and a significant number of workers were laid off. And where caps exist, non-unionized workers actually end up better off because they don't pay dues. When policymakers discuss the future of Canada's $80-billion-a-year health-care system, their main concern is that they have not yet figured out how to get adequate numbers of employees in the right jobs at the right place at the right time.
There are periodic regional shortages of doctors, and there are massive shortages of nurses predicted. But the real ticking time bomb in the system is the growing inability to attract and retain homemakers.
"This is where the buck stops when the health system cuts back," said Ms. Burgess of the Red Cross. "Once people are home and need care, there's nowhere else for them to go. You can't say no."
When there are shortages of homecare workers -- as there are with increasing frequency across the country -- there is a ripple effect throughout the system from emergency rooms to nursing homes.
What is going to lead to the resolution of this staffing crisis, Prof. Keefe predicts, is some sensational event that grabs the news spotlight. "In this country we tend to fiddle around with these things until they degenerate into a crisis or a scandal, then the media get involved and the government acts. It's a pretty poor way of formulating public policy."
Cheryl Allen is a home-support worker in Fredericton with eight years experience. She is paid $7.49 an hour, with no overtime pay and no benefits. Here is one day's work schedule:
08:30-10:30 -- A client with Parkinson's disease. He requires a bed bath, catheter and colostomy care, skin care and bandaging of chronic wounds. Ms. Allen then helps him out of bed, helps with dressing, prepares breakfast and does cleaning. Then she helps with physiotherapy exercises. (She does this visit seven days a week.)
10:30-11:30 -- Drives to Beaver Dam, a small community outside Fredericton.
11:30-13:30 -- A frail elderly client in her 90s. Does the week's housecleaning and laundry, then takes her to run errands, including grocery shopping. (This visit is once a week.)
13:30-15:30 -- Free time. Drives 60 kilometres back to town. Ms. Allen eats lunch, feeds her dogs, and tries to do her own errands.
15:30-17:30 -- A client with multiple sclerosis. Does housecleaning, toileting, suctioning of his airways and some physiotherapy. Ms. Allen is allocated one hour's pay for this visit, but stays two because of the workload. (She visits this client seven days a week, but times vary.)
17:30-19:00 -- Free time. Has dinner with her daughter.
19:00-20:00 -- Returns to client with Parkinson's. Repeats morning routine of catheter and colostomy care and bandaging, helps him to bed.
20:00-21:30 -- Returns to client with MS. Cleans gastric tube, does catheter care, bed bath and lifts him out of wheelchair into bed. Sets up breathing apparatus for the night. As he sleeps, Ms. Allen cleans the machinery.
21:30-23:00 -- Free time. Goes home, feeds dogs, checks on daughter.
23:00-07:00 -- A client with severe osteoperosis. Requires an overnight sitter because of mobility problems and need for pain management. Ms. Allen sleeps approximately two hours during the night, before a similar routine Saturday and Sunday. Monday to Thursday shifts are also similar, except that she does not do any overnight work. She has just started taking every second weekend off because of exhaustion.
One-stop access centres simplify finding services
Toronto -- The face of homecare has changed dramatically in the past decade, and nowhere more so than in Ontario.Since 1990, total government spending on homecare in Canada has doubled to $2.1-billion, with the country's most populous province accounting for more than half.
The clientele has gone from primarily seniors who needed help cleaning their homes to a mixture of postsurgery patients, frail seniors and disabled people who need long-term daily care, and palliative-care patients.
But the most profound changes have been administrative and political.
In Ontario at least, homecare is an issue that moved from behind closed doors to the cabinet table, with the appointment last July of Cam Jackson as Minister of Long-term Care with responsibility for seniors.
The minister is perpetually on the hustings, boasting that Ontario is a leader in per-capita spending and the only province to offer its citizens "visiting nurses, physiotherapy and homemaking in the spirit of the Canada Health Act -- without an asset test, income test or means test."
Before Mr. Jackson's appointment, the Progressive Conservative government created, as a centrepiece of its massive health reforms, what it called community-care access centres. Ontario was not the first province to take a one-stop-shopping approach to long-term care, but it did so swiftly and aggressively. In the process, it addressed the principal complaint of family caregivers: that they had no idea where to turn for help.
Until 1996, there were at least 1,200 organizations in Ontario offering home nursing and homemaking services, with governments purchasing their services via 74 placement co-ordination services and regional homecare programs. Under this system, the government argued, agencies were not accountable and services varied dramatically from region to region.
Now there are 43 government-financed access centres that purchase services from agencies through a competitive bidding process.
Ontario is now the only province to allow for-profit companies to bid on all homecare contracts, a move that critics have labelled a massive privatization in health care. (Some provinces deliver homecare through government agencies, while most have a form of managed competition.)
In 1997, Manitoba made a similar move, but there was only one bidder. Homecare workers staged a strike, and the government reversed its decision, limiting bidding to only 10 per cent of services.
In Ontario, where there is $1-billion up for grabs, the competition has been cutthroat. Costs have come down markedly, and so have wages (which account for about 85 per cent of homecare costs). Predictions that not-for-profit agencies would be wiped out have not proven true, although in this year's bidding there will be much more head-to-head competition with for-profit agencies.
Allen Prowse, national program director for community home-support services at the Red Cross, said competitive pressures led the humanitarian agency to streamline its operations, and it cut administration costs by 20 per cent in the process. The Red Cross provides about 40 per cent of homemaking services in Ontario.
The principal complaint about Ontario's bidding process is that it has not been accompanied by the establishing of minimum quality standards and guaranteed access. Unlike hospitals, the access centres can turn away patients, and they do. Demand for services has been growing by about 20 per cent a year.
Most clients who received homemaking services are now being referred to private cleaning services, and an increasing number of users are supplementing their basic publicly funded services with privately purchased nursing and support services.
The jury is still out on quality.
The problem is that the only measure of satisfaction the government has adopted is cost, said Joe McReynolds, executive director of the Ontario Community Support Association. Homecare wages are dropping sharply -- by about $2 an hour in the past year. (The only reason they have not fallen further is that Ontario has set a floor of $9.51 for homemakers.)
At a recent conference, Mr. McReynolds spoke of seeing two job ads side by side in a newspaper, one for an animal-control officer at $18 an hour and one for a personal-support worker at $10.10 an hour.
"People who take care of our mothers . . . are paid less than those who round up stray pets." In such an atmosphere, it will be difficult to maintain qualified workers, Mr. McReynolds said.
Photo Essay by Fred Lum