Health Committee on May 13th, 2020

[Isobel Mackenzie]

Thank you, Mr. Chair.

Thank you for inviting me to give my thoughts and observations on our initial response to COVID-19 as it relates to seniors. I say “initial response” because we're not through it yet. Inevitably we're going to discover some future issues that are not obvious right now. As you know, we're only two and half months into what is going to be a year long or 18-month journey.

I think most of us have seen, as we have responded to this pandemic, that fault lines have appeared that relate to a lot of things in our society and our economy, but particularly as they relate to seniors. I think we need to recognize that the impact of COVID-19 is different for seniors depending on their income, their social and health status. What one senior experiences in not necessarily what every senior is going to experience.

I've tried to break it into categories to look at where these differences are. If we look at the category of low-income seniors, I think there has been a different impact on them than other aspects of society. As most of you probably know, seniors have the lowest personal income of any age cohort over 25. They are very sensitive to small cost increases.

It's true that seniors have not yet felt an impact from a decrease in income. Pensions obviously have remained the same. Impacts from investment income haven't really been felt yet. The degree to which that will be felt is still to come. I'm sure many MPs on this committee have constituents who are low-income seniors who are sensitive to price increases. I'm sure you've heard about the experience of increases in food costs, in part because of actual increases in food, and in part because seniors who normally go from supermarket to supermarket or store to store looking for specials have not been able to do so. A $50 or $60 a month increase in the food bill of a low-income senior's budget does have quite an impact.

Low-income seniors are also less likely to be savvy in the virtual connections we have, like Zoom, in part because they are less likely to have devices and they are far less likely to have the Internet. One of the things that the federal government can look at in the future is how we're going to be able to provide low-cost Internet. We have focused a lot on the provision of the Internet to all parts of Canada, including rural parts. That is very important. We cannot ignore the fact that the Internet is also very expensive, especially for low-income people, and particularly for low-income seniors who can't necessarily bundle everything together on a smart phone.

I think the impact on low-income seniors wasn't immediate. It wasn't on day one, but it has compounded over time. I think it will continue to compound as they are susceptible to these small price shocks that I think we're going to see over the next year.

As we practise our safe distances, our six feet apart, as we isolate at home and certainly as seniors are made aware of the need to stay away from people more so for them than others, we need to recognize that seniors are more likely to live alone. Indeed, 23% of people 65 to 85 live alone. That goes up to 41% when you look at people 85 and over. Compared with the population under the age of 65, less than 10% between the ages of 35 to 65 live alone. When you're socially isolating in your own home, it looks different when you have a partner or kids to talk to versus having nobody to talk to. I think we have to be sensitive to that impact, which is going to build over time. You're not going to notice it as much in week one or week two, but as the weeks become months, I think we're going to have to recognize the profoundly disproportionate impact on seniors because they are disproportionately likely to live alone.

The COVID-19 response looks different depending on your health status as a senior. If you're 65 or even 90 and you're robust and living independently and can perform all your activities of daily living and your independent activities of daily living on your own and you're living with your spouse and you have sufficient income, that looks one way. It looks not unlike how many of the rest of us are responding to COVID-19. However, if you are like the majority of seniors over the age of 85, you need some help with your activities of daily living and perhaps even with your independent activities of daily living, so you're going to feel an impact. Certainly Marissa, and I suspect others, will talk about home care as well and how the availability of home care and the impact of COVID-19 on its delivery is going to affect some seniors.

COVID-19 will also have a mental health impact on some seniors as it dawns on them just how vulnerable they are when they need some help with their activities for daily living. They may not have appreciated it when they were getting the steady flow of home care, but as it became apparent that there might be some challenges in having that continue, I think there might have been an undercurrent of additional anxiety among some seniors as they recognized how vulnerable they were going to be when living alone without the ability for others to come in and help, although to the best of my knowledge we didn't see that big of an impact. Certainly here in British Columbia, we fortunately did not see an impact on home care services for seniors living at home.

There are also those who are in assisted living and in the long-term care system. For them, the economic challenges aren't profound, but the other challenges have been. Number one is the fear, but there is also the inability to visit with family members, which is still the state of events here in British Columbia and I think in every other province to date. Hopefully we will find a way to reintroduce some capacity for family visits in a way that's safe so that over the next year, we can allow some of the connection to happen that's been lost over the last couple of months. That has had a profound effect.

There are also the family members of those living in long-term care and assisted living. They will be profoundly affected on two fronts: in their inability to visit their loved ones and in what they are hearing, seeing and learning about what is happening in parts of our long-term care systems. I think it is important to acknowledge and understand that many care homes have had no outbreak of COVID-19, and some that have had outbreaks of COVID-19, like those here in British Columbia in the last month or so, have been able to swiftly contain their outbreaks. I think it's important to remember—and Gudrun talked about when we went out and surveyed residents in long-term care pre-COVID-19—that while many of them do not want to be there, do not feel it's home-like and do not receive the kinds of things they want to receive, many do as well.

I found it interesting when we went out and surveyed all of our care homes. I don't think it had been done to this magnitude in any other province. Every single publicly funded care home, every single resident and every single family member was surveyed by my office, independently of the care home and the health authority, and literally 50% of them said home care was pretty good and 50% said it was not very good. Many of those people were in the same care home.

We have to appreciate and understand that your experience in a long-term care facility is linked to a number of things: your expectations and experiences before you went into a long-term care home and your health status in a long-term care home. Not surprisingly, levels of dissatisfaction rose as levels of complexity rose. The more help you needed, the less satisfied you were. The less help you needed, the more satisfied you were. I think that speaks to some of the fault lines that have been very publicly revealed now in the staffing levels and staffing models that we have in long-term care throughout Canada. Those folks have a different experience with COVID-19.

What are the major challenges that we have? Certainly, I want to start at the income level. There is no doubt that for about a third or maybe 40% of Canadian seniors, income is a problem. Many seniors have sufficient income, arguably more than sufficient income, but we can't forget....

One measure that I use is the GIS measure. If a senior is on GIS, they have a pretty low income. It's linked to their—

[The Chair, Liberal, Ron McKinnon]

I'm sorry, Ms. Mackenzie, could you wrap it up very soon?

[Isobel Mackenzie]

Okay.

I think we need to look at that, and when we look at long-term care, as I think others have spoken to, there are things that we need to do there and in home care. Again, about 20% of people could live in the community if we had a better home care system.

In wrapping up, I also want to talk about the silver lining that I have seen in all of this, particularly here in British Columbia. That is the outpouring of support we have seen for seniors I believe across Canada, and absolutely here in British Columbia. To put it in perspective, we opened up a 211 “call if you need help or call if you want to volunteer” line, and it crashed. Thousands of people were calling in to volunteer to help seniors. In the last seven weeks, volunteers in B.C. have delivered over 54,000 services, and there are many more. Just through this one program there were 36,000 virtual visits.

[The Chair, Liberal, Ron McKinnon]

Wrap up, please.

[Isobel Mackenzie]

I think we need to look at building on what I think of as this great repository of desire from Canadians to make things better for seniors in Canada as well as in British Columbia.

Thank you.

[The Chair, Liberal, Ron McKinnon]

Thank you.

We go now to the Canadian Association for Long Term Care, to Ms. Jodi Hall, chair.

Please go ahead.

[Jodi Hall, Chair, Canadian Association for Long Term Care]

Thank you.

I'd like to thank the members of the committee for inviting me to present here this evening....

Can you hear me okay?

[The Chair, Liberal, Ron McKinnon]

I can hear you well, except I'm getting the French translation channel.

[Jodi Hall]

Yes. I think I'm experiencing that as well. I'm sorry.

[The Chair, Liberal, Ron McKinnon]

We will have to sort that out.

Can we check that we're getting the proper translation on the English channel?

Okay. Great. Now I'm getting the English channel, and it looks like we're good to go on the French channel.

Ms. Hall, please go ahead and start over. Thank you.

[Jodi Hall]

Thank you for the opportunity to speak to the committee this evening.

The Canadian Association for Long Term Care is the leading voice for quality care in Canada. Our members deliver publicly funded health care services to seniors right across the country.

I will start by acknowledging the seniors who have died of COVID-19. Our hearts are with those families. I'm sure that you all join me in extending deepest condolences to them.

I'll also take this opportunity to thank our front-line health care providers, who have worked tirelessly and with great compassion to deliver the care that has been required.

As we reflect on COVID-19, we will take the time to understand what could have been done differently, but we believe the impact of COVID-19 on long-term care homes could have been mitigated if governments had been proactive in supporting the sector prior to this outbreak.

Some of the challenges I will be discussing today have been exacerbated by COVID-19 but really represent systemic issues our members have been raising for many years. I want to be clear that all types of homes have been affected by COVID-19 and each have had a different type of experience. This has been an extraordinarily difficult and painful time for everyone involved, including residents and families, the front-line staff, but those who operate long-term care homes as well. We just ask that the efforts of the nation continue to focus on rallying and supporting those who are in long-term care homes.

The differences in experience with the virus have been based on a range of factors. These factors have included infrastructure, the staffing situation in the homes both pre-outbreak and during, and how rapidly the homes have been able to access personal protective equipment and staffing support when they really needed that assistance.

In the early days of the pandemic, testing, the ability to cohort their residents, and infection control measures were focused on seniors and caregivers who showed symptoms. Infection control experts and public health scientists now understand that asymptomatic carriers are highly contagious and that the incubation period for COVID-19 is far longer than for other viruses. As a result, homes that were affected early by the virus seem to have been hit the hardest.

I'd also like to clarify some misconceptions. Any and all care that is provided in long-term care homes, whether that care is provided by a doctor, a nurse or another type of health care provider, is covered by provincial governments. Each province regulates long-term care a bit differently, but generally the homes receive a funding envelope for care, programming and staffing.

In Ontario, for example, the government funds all long-term care homes with highly prescriptive expenditures, which are audited through the government departments that oversee them, and the findings of those audits are always reported back to government. With every dollar that is allotted to nursing, to personal care and to food budgets that are specifically earmarked, if there are any dollars left over in those envelopes, they have to be returned to the provincial government; there is no profit on any of these funding envelopes.

In other areas of operation, the staffing levels are highly prescribed and the funding model is extremely complex. It's highly prescriptive, tightly regulated and monitored on a regular basis by each provincial government.

I will now speak to some of the systemic issues we have noted that we feel have been an exacerbating factor with COVID-19.

The first one is infrastructure. Many older long-term care homes have three- and four-bed wards. They do not have private rooms, and it makes it a challenge to implement cohorting and isolation measures. They generally have narrower hallways and there's only one centralized dining room in the majority of homes, which makes it much harder to socially distance residents appropriately.

The Public Health Agency of Canada released an interim guidance document on infection control for long-term care homes, and some of the guidelines such as restrictions to certain work zones and the use of single rooms for certain types of care are almost impossible for homes to implement across the board, especially in these older facilities. Any existing outbreak management plan that these older homes have, including the isolation of asymptomatic residents, is really hindered by inadequate space and the layout availability, and we can see just how devastating shared rooms can be in an outbreak.

We know that there are at least 400 long-term care homes across the country that require updating and some form of modernization. It is imperative that the federal government support this sector by providing access to existing federal infrastructure funding, and there are many ways this could be administered. We have also noted that Minister McKenna recently spoke about financial support for shovel-ready projects in the post-pandemic stimulus package. These projects, indeed, are shovel ready and we certainly could move forward quickly with federal support.

The other systemic issue that I would like to raise is with regard to health and human resources. This is a challenge that is facing this sector and is ongoing almost at a crisis level across the country. Attracting and retaining individuals for a career in senior care has become increasingly challenging, especially when preparing for the aging demographic transition that we're experiencing right across the country. We're caring for individuals who have multiple and complex conditions much more than we have seen in the past.

We are asking for a health and human resources strategy for the long-term care sector. This is desperately needed and it should focus on the right number, the right mix, the geographic distribution of providers, as well as an appropriate setting for providers to deliver the care in. Through the leadership of the federal government, there must be collaboration with the provinces, the territories and the long-term care sector to develop and implement a pan-Canadian health and human resources strategy.

In closing, there are systematic challenges that the sector has been grappling with for many years, which we have identified. This has been fully exacerbated by the event of COVID-19. We have asked before, and we are asking again, that the federal government provide assistance to the sector to ensure that seniors have the housing and the care they need, not just in a time of crisis, but every day.

I thank you for giving me this opportunity to speak, and I certainly look forward to questions.

[The Chair, Liberal, Ron McKinnon]

Thank you.

Dr. Armstrong, you can go ahead. You have 10 minutes, please.

[Dr. Pat Armstrong, Distinguished Research Professor of Sociology, York University, As an Individual]

Thank you for the opportunity to appear on this critical issue.

In the 1980s, the Ontario Pay Equity Commission asked me to study the health sector to see who would be missing from the legislation, a request that began my research into long-term residential care, or what are most commonly called nursing homes.

Most recently I've been the principal investigator on a 10-year interdisciplinary project, called “Re-imagining Long-Term Residential Care: An international study of promising practices”. This research took international interdisciplinary teams, made up of mainly senior scholars, into nursing homes in six countries: Germany, Norway, Sweden, the U.K., the U.S. and Canada. We observed, interviewed and reflected together on what we saw and heard over the week-long span we spent in each of these homes.

In this, and in a number of other related projects, we've confirmed our central assumptions, assumptions I want to set out here.

First, we need nursing homes now and in the future for those who require 24-hour care. Such care cannot be provided in private homes, not only because many people do not have homes or at least homes suitable for such care, but also because the care required is skilled and demanding. Your grandmother and mine never provided this kind of care, because few people lived into old age and even fewer lived with the kinds of conditions and technologies required today. Of course, it is primarily women, unpaid for the work, who provide care at home now, often to the detriment of their health now and in the future. We need to plan for more, and more accessible nursing homes where 24-hour care is provided.

Second, the conditions of work are the conditions of care. These conditions certainly include adequate staffing in terms of numbers, composition, training and continuity. These conditions also include pay and benefits, especially paid sick leave, and decent terms of employment, such as hours of work and shift length as well as choices about them. The conditions involve equipment that goes well beyond the personal protective equipment that has appropriately received so much attention today. It must include such things as lifts and carts, when we think about the health risk to the residents and staff.

However, the conditions for care include much more than that. Reasonable autonomy, the time to provide the care that training and experience have taught workers to provide, and support for teams are critical conditions. Union protections, especially the right to say no to on-site conditions and to the violence that is far too common, are also essential conditions. Similarly, the physical structure of the home, as we've just heard, and its location shape care.

This is not a complete list of conditions that are necessary for care. We have to take all of them into account in planning for care both during and after the pandemic. Otherwise, we will not have a labour force, as the OECD and the ILO recently made clear in their report in December.

Third, these conditions have to take into account all those who live in, provide paid and unpaid work in, and visit in long-term residential care. Our research clearly shows that it is not only direct nursing care that is critical. While there has been recent media attention on cleaning in pandemic times, there has been virtually no discussion of the laundry and dietary services that are also particularly important now but are always essential to care. Moreover, families do much more than provide the hugs that have received so much media attention. They also fill gaps in other care work, as do the privately paid companions many families provide. Volunteers, too, make critical contributions to the social activities and the physical environment, contributions that are essential to care in long-term residences.

In recent years, this unpaid work of families and volunteers, the paid work of non-staff and the unpaid work of paid staff have all expanded to fill the gaps in care, well before the pandemic. We need to address the gaps in care at the same time as we ensure that everyone who provides care has the training required.

Fourth, this is skilled, gendered work. We've heard a great deal about the heroism of these workers, which may end up like Mother's Day, a one-day recognition. Pay equity legislation grew out of research demonstrating that there is systemic discrimination in the labour force. This discrimination renders invisible and undervalues the skill, effort, responsibility and working conditions involved in women’s work.

This is definitely women’s work, whether carried out by staff, contractors, families or volunteers. More than four out of five of those employed in this sector are women, and a significant proportion are new to the county and/or are racialized. There is a faulty assumption that this is work any woman can do by virtue of being a woman. The value of and the skills involved in the labour may be further undermined by the fact that this is mainly women looking after older women.

I am reminded of an interview I did with a human resources manager of a large home in Norway. I asked her what surprised her when she went into the home after working in a major media corporation and she said, “I couldn't believe how hard these women worked.” When I asked what she would do if she was in charge of the country, she said, “I'd pay these women what we pay the men on the oil rigs, because these women work harder.”

We have to recognize this work. We have to support it as skilled, demanding work that carries considerable responsibility. We have to do so not just now but in the future.

Fifth is that context matters. We talk about promising practices in our research rather than best practices because there are often multiple ways of making care conditions as good as they can be. We can learn from other countries and jurisdictions as we recognize at the same time that what works well in Toronto may not work well in rural Nova Scotia. Nevertheless, we can establish broad principles for setting conditions, and we must do so to protect workers, residents, families and volunteers.

Sixth, the search for profit does not lead to better quality care, greater efficiency or more choice, nor do many of the practices taken from that sector. Indeed, such privatization can lead to the reverse. We have to ensure that our public money goes to care rather than to profit, and to democratic decision-making rather than shareholder decision-making. At the same time, we need standards for all homes and to make sure those standards are practised and enforced.

While there are many other lessons we have learned that would take me well over my 10 minutes, let me end by saying this all leads to the need for federal leadership, as many here have said today. I would argue that it should be through legislation that is similar and parallel to the Canada Health Act, legislation that provides conditional funding based on evidence that principles and criteria are followed.

We have a host of research and commissions that provide enough evidence and advice to move forward quickly. However, in doing so, we need to ensure that the voices of those who live in, provide paid and unpaid work in, and visit long-term residential care are heard. We must ensure that nursing homes are not only safe and accessible, but also organized, funded and designed to make life worth living for all of those who live in, work in and visit long-term residential care.

Thank you. I'd be happy to answer any questions.

[The Chair, Liberal, Ron McKinnon]

Thank you.

We'll start our rounds of questions now. We'll do three rounds and start with Ms. Jansen.

I would also like to remind everyone to try to remember that our terms of reference for these meetings are solely to receive evidence relating to the government's response to the COVID-19 pandemic.

Ms. Jansen, please go ahead for six minutes.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

First, I want to thank everybody for being here.

Pat and Ms. Mackenzie, you both did some amazing work on reports, so I thought I would start with Dr. Armstrong.

In your report about reimagining long-term care.... In our committee we've been hearing from many witnesses and a number of them have made the assertion that public long-term care facilities have performed far better than private during the pandemic. Ms. Langolf suggested in her presentation that phasing out private long-term facilities is the fix we need, whereas I was reading your report, and I thought it revealed that the issue is far more nuanced than just saying if the government were running these facilities this never would have happened.

Clearly, one of the major challenges in the beginning was the scarcity of PPE and the need to ration PPE. In your estimation, what grade would you give the Public Health Agency of Canada on its level of pandemic preparedness, especially with regard to PPE availability and distribution?

[Dr. Pat Armstrong]

I think it is complicated and I think, as several people have said, we will perhaps not know how complicated until this is all over. Obviously there wasn't enough preparedness in spite of what we saw in the SARS Commission report, which did say we should stockpile for a future pandemic. Although it has to be said that in all the SARS reports, the emphasis was on hospitals, and that has been one of the problems. Not only did we not have enough and the Public Health Agency didn't stockpile enough, but when that equipment was available, it went first to hospitals.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

You make a number of short-term and long-term recommendations at the end of your report, which I very much appreciated. Of those recommendations, which ones are your top three, the three that would have made the most difference in protecting seniors in long-term care across Canada during this pandemic?

[Dr. Pat Armstrong]

Staffing and the conditions of work have to be at the top. As we look at what's happening, and as we heard about B.C. in terms of the strategies that were taken early to address this, we see it's about staffing. We've known for a very long time that we need more staff. I can't tell you how many times we've been told there are not enough hands. Perhaps I could say one more thing. I've just been talking with our partner in Norway, and they've had very few deaths in the Norwegian nursing homes. One of the factors there, he said, was that the proportion of their hands-on staff is significantly higher than anywhere else.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

I understand that here in B.C. staff was basically moved from facility to facility. I thought it was really interesting how staff were using the same equipment as they moved from patient to patient and from facility to facility, because we were obviously rationing PPE. I know in my industry everybody is required, as they come into a vegetable facility, to put on an outfit that they take off at the end. You wonder how much could have been done had we had that sort of PPE available. Maybe Ms. Mackenzie can speak to it.

In regard to “A Billion Reasons to Care”—I love your title there—I was struck by the statistics that you share regarding the difference between for profit and not-for-profit long-term care facilities. As I mentioned, people are making the bold assertion that public facilities are far better than private. Just down the road from me here there's a private care home that actually banned provincial health care workers from being sent to that facility by the local regional health authority, because they were only given two sets of gloves and two masks to use for the month.

Again, how important is the factor of the PPE, as opposed to public or private care? We have some amazing facilities here. Look at the dementia village we have here in Langley. It's an absolutely amazing facility. It's private but a wonderful option for seniors.

[Isobel Mackenzie]

When you look at British Columbia so far, there is quite a difference in the probability of an outbreak in a contracted care home versus a health authority owned and operated care home. That is a very clear pattern that's established. I think 8% of the outbreaks are in owned and operated sites, yet owned and operated sites are 37% of the sites. There is quite a difference here.

The PPE issue is, I think, complicated because part of it is the lack of understanding of the appropriate use of PPE. This is something strong clinical leadership can help in a care home setting. It's not clear. When we get all the data and we can sort through all of it and look for the patterns around that strong clinical leadership, for me, one of the litmus tests is when I hear a care home talk about N95 masks and the care home has no outbreak. You don't use an N95 mask in a situation where there is no outbreak.

There is the issue of the supply, writ large, and then the appropriateness of the use of PPE, irrespective of the supply. When we talk about our not being prepared.... I've spent 20 years in delivering both home care and long-term care, and here is my observation: We completely underestimated—for want of a better term—the freak-out factor.

We are accustomed to outbreaks in long-term care. We handle them every year. We had 185 of them last year in British Columbia. We have protocols and we notify, but those are influenza and norovirus. We completely underestimated that, when it was COVID-19, we needed....

This is where I think that, in British Columbia—because we had the first outbreak and perhaps because in the first outbreak the care home wasn't able to respond—public health got in there and saw how quickly it needed to get in there and take control, and then was able to keep doing that. I think that is what has happened in British Columbia. It is public health's going in right away. When I look at what has happened in other parts of the country, that wasn't as quick off the ground, in part because we had the first outbreak here.

[Tamara Jansen, Conservative, Cloverdale—Langley City, BC]

I'm wondering—

[The Chair, Liberal, Ron McKinnon]

Thank you, Ms. Jansen.

We'll go now to Mr. Kelloway, please.

Mr. Kelloway, you have six minutes.

[Mike Kelloway, Liberal, Cape Breton—Canso, NS]

Thank you, Mr. Chair.

Hello, colleagues.

Before I begin with my line of questioning, I just want to say that it's a real privilege for me to hear from the witnesses today and for all of us to hear from the witnesses today. In my riding of Cape Breton—Canso, we have a large seniors population, and I keep them in mind every day. Throughout this pandemic, I've seen just how much citizens throughout the riding have come together to support seniors in our communities during these challenging times. I want to thank each of you for the work that you're doing in this regard.

My question is for Dr. Armstrong, and this has been referenced. You wrote a report that identified staffing issues, shortages of staffing and low wages for health care workers in long-term care facilities as having contributed to the spread of COVID-19. We know that the spread of the illness, including the common flu, has been noticed very quickly throughout long-term care homes even before COVID-19.

In your research, what solutions have you concluded can address these staffing issues and can prevent the spread of communicable diseases?

Also—I think you've alluded to this—can you talk a little about the best practices that you have been able to identify that long-term health care facility administrators should be aware of?

[Dr. Pat Armstrong]

Staffing has been identified in report after report, not just in terms of numbers but also in terms of training and distribution.

If we'd had adequate staffing levels to start with, we wouldn't have had the kind of desperation that we've seen. If we'd had full-time jobs, we wouldn't have to be introducing the kinds of practices that were introduced in B.C., because those would already be what was happening in homes. If we had surge capacity within the homes in terms of the labour force and in terms of the physical space, then we wouldn't be having this crisis either, I don't think.

We've known this for a long time, and if we don't learn the lesson from this, then I think we are going to be in worse trouble in the future. This is one of the reasons why we want to talk about the future as well as the present.

We have a lot of evidence that 20 years ago they were saying that 4.1 hours of nursing care per resident per day was essential, and that was before we had residents with the levels of complication that we have now.

Charlene Harrington, who is one of the biggest experts in the U.S. on this issue and who I was talking to this week—she is part of our research team—said that they're now saying that it should be 4.9 hours per resident per day, given the level of acuity that is the case in most homes in Canada. We don't have any province or territory that comes even close to that, and that's in regular times.

[Mike Kelloway, Liberal, Cape Breton—Canso, NS]

In regular times, absolutely, and that was probably 20 years ago, as you mentioned.

Just to stay with you for a second, many witnesses have come to the committee on various topics regarding COVID, and there seems to be a bit of a common thread around greater federal oversight in a variety of ways. You referenced that here in this session. Can you elaborate a little more as to what that looks like to you?