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Reviews / Comptes Rendus

Patricia M. Baranek, Raisa B. Deber, and A. Paul Williams, Almost Home: Reforming Home and Community Care in Ontario (Toronto: University of Toronto Press 2004)

ALMOST HOME offers an in-depth account of the changes in long-term community care policy in Ontario proposed by three successive governments: Peterson's Liberals, Rae's New Democrats, and Harris's Progressive Conservatives. Using a neo-institutional perspective the authors highlight how divergent stakeholder interests, differing societal ideas, and lack of institutional constraints allowed each government to exercise a "strong" role in shaping service delivery models for this sector. They contrast the proposed changes in service delivery for home-based care to the strikingly unchanged physician-dominated primary care system over the same time period.

Supported by stakeholder interviews and document analysis, the authors make a strong case that opportunities for system-wide changes were possible because of favourable policy circumstances. First, community-based services differ from physician and hospital services because they are not covered by the Canada Health Act (1984). Consequently it becomes possible for provincial governments to limit the availability of care without confronting the Act's five principles: universality, comprehensiveness, reasonable access, portability of coverage, and public administration. Second, the stakeholders most impacted by service delivery in this sector struggled to mobilize because they had differing interests and they represented small organizations with limited financial resources and few paid administrative staff. Third, a "grey area" of service provision, the community long-term care system, encompasses the area of social care associated with the regular activities of daily living such as getting out of bed, taking a shower, getting dressed, eating food, going shopping, washing clothes, and maintaining a home. Ideas regarding the role and responsibility of government in these "softer services" are more ambiguous than those pertaining to medical care.

The authors also provide some important context which helps to illuminate why governments chose to focus on long-term community care. With the perceived rising demand in care due to an aging population, decreasing fiscal transfers from the federal government, rising provincial debts and deficits, each government was interested in cost containment. Community care appeared to offer a cost-effective alternative to more acute institutional care. Further this sector was considered a "patchwork quilt" of services consisting of small independent organizations in need of coordination.

Devoting each chapter to a newly elected provincial government, the authors offer a detailed account of the variation in proposed models. Peterson's Liberals represented an attempt at incremental change. They proposed to establish Service Access Organizations [SAOs] which would oversee acute home care services, public nursing homes and community organizations (not-for-profit agencies which provided meals on wheels, transportation, adult day programs, and homemaking). This amalgamation of services would provide service users with one point of entry into the system. Existing organizations could become SAOs only if they were not current service providers, thereby separating the functions of assessment and provision of services. The authors emphasize that amalgamation meant placing the responsibility for service allocation under one ministry. Previously home care services were governed by the Ministry of Health and community services and placement services were governed under The Ministry of Community and Social Services. According to the authors, the SAO model would move home care services out of the OHIP envelope, effectively "mov[ing] [home care] out of the public realm into the private one of user fees and co-payments." (91) Their argument regarding the funding impact of this decision is somewhat overstated given that home care was never a protected program like hospital-based and physician-led services. However, their analysis regarding the lack of stakeholder resistance to the proposed amalgamation provides well substantiated support to their thesis. That the model was never realized was a product of a lost election not a mobilized community.

Rae's NDP government envisioned a more drastic change to the system. They proposed the creation of quasi-governmental organizations which would replace existing service providers. These organizations would serve to assess, manage, and provide direct service to citizens. As a concession to existing service providers the Multi Service Agencies [MSAs] would be entitled to contract 20 per cent of services to outside agencies, preferably to not-for-profit service providers. Further, the government drafted and eventually passed the Long-Term Care Act (1994) which officially governed over community services, nursing home services, and home care services. Although the NDP did succeed in passing the legislation, they met more resistance than the Liberal government. One reason was that community organizations had formed a provincial association and had been given some funding from the government to consider alternate delivery models. Another was that for-profit and not-for-profit providers found themselves jointly opposed to these changes. The authors emphasize that divergent interests still existed among hospital-based workers and home-based workers. With pending hospital cuts, displaced hospital workers would be competing with community workers for employment in the new MSAs. They suggest that these competing interests interfered with lobbying efforts. In the end, the Long-Term Care Act was successfully passed but the MSAs were not established because the government lost the subsequent election. The authors highlight that this NDP term represents another example of a "loosely" organized policy environment. However, their analysis also provides evidence of a mobilization effort which delayed program implementation and required the government to offer concessions. More attention to the "exception" of this case may have provided useful insight into how communities can impact upon policy.

Harris's Progressive Conservative government created and eventually implemented 43 Community Care Access Centers [CCACs]. Like the Liberal model, these organizations would broker services to service providers. However, influenced by market ideology, service contracts would be allocated based upon a system of managed competition. This would open the process to both for-profit and not-for-profit service providers who would be competing for contracts based upon a formula of best quality and best price. While labour was strongly opposed to these changes in long-term care they were occupied with other effects of Harris's Common Sense Revolution and could not devote their full attention to the issue. Further, not-for-profit providers had little influence over this government and could not launch a successful lobby effort. Government ideology prevailed and the CCACs were eventually implemented. The retreat of the state was formalized further by government regulations which would legislate service caps on the provision of homemaking services and professional in-home services. This served to limit CCAC control over service delivery and downloaded more responsibility from the public domain into the private lives of service users and their families. The authors' arguments are well substantiated in this case example. During the Conservative term a drastic change to the community-based system was both proposed and implemented and the authors do an excellent job of analysing how this "strong government" was enabled.

By offering this thorough analysis of the long-term community care system Particia Baranek, Raisa Deber, and Paul Williams illustrate how governments can successfully implement policy changes especially when they face "loosely" organized stakeholders and few legislative constraints. Unfortunately the authors pay much less attention to their third criteria for government-driven change: that of divergent ideas. When they introduce their theory they highlight that Canadians are more divided on the importance of government support for "softer services" such as home meal delivery than on the right to access basic medical services. Quite possibly this divide explains the lack of institutional constraints in the area of community care. However their data analysis offers only a few sporadic comments highlighting this issue. A comprehensive analysis of this debate or lack thereof in government deliberations, the media, and at the community level may have offered more depth to their analysis.

As testament to Baranek et al.'s theory, a newly elected provincial government (Dalton McGuinty's Liberals) has meant a revisiting of previous design decisions in community-based services. Most recently for example, Elinor Caplan was commissioned to review managed competition in Ontario. Although her report supported this system, she put forward a series of recommendations, one of which included the granting of extended contracts to organizations with "preferred status." She also recommended a preference for not-for-profit service providers when bids are tied on all other levels. As predicted by the authors, community long-term care continues to offer governments the opportunity to follow their own ideologies and reverse decisions made by previous governments.

Overall, Almost Home is an exceptionally well-researched and well-written account of the changes in community-based long-term care in Ontario over an eighteen-year period. Those interested in policy analysis or home care would benefit from reading this sophisticated book.


Tamara Sussman University of Toronto

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