The Victorian Order of Nurses was, for more than a century, the primary provider of home and community-based care in Canada.
Now it is teetering on the verge of bankruptcy.
Late last week, the VON shut down operations in six provinces – Alberta, Saskatchewan, Manitoba, New Brunswick, Prince Edward Island, and Newfoundland and Labrador – and filed for protection under the Companies' Creditors Arrangement Act.
It will continue to operate in Ontario and Nova Scotia – at least for now.
The collapse of the iconic organization, founded in 1897 by Lady Aberdeen, was swift and brutal.
It also serves as a cautionary tale about Canadians' tortured relationship with medicare, in particular the conflicting desires to cling to our history of charitable provision of care and achieving efficiencies with unforgiving business models.
VON was trapped, and ultimately crushed, by that contradiction.
It was not the first – the Canadian Red Cross Society's legendary blood transfusion service flamed out in an even more spectacular fashion with the tainted blood scandal where 20,000 recipients contracted hepatitis C or HIV – and it will not be the last. Canadian Blood Services has taken over the former Red Cross role.
The health-care advocacy group Friends of Medicare said the near-demise of the VON is proof that "experiments in private care must be ceased."
But VON's story is much more complicated than the "public/good, private/bad" and "not-for-profit/good, for-profit/bad" narrative.
For a long time, governments funded not-for-profit groups in the health and social services sector – hospitals, home care, group homes, the Red Cross and so on – in a pretty loosey-goosey fashion. These groups did good, and they were funded relatively well.
But as budgets soared, new accountability measures were put into place. In the home-care sector, for example, competitive bidding was introduced.
Stodgy old organizations such as the VON were not ready, and did not adapt. Their market share fell from more than 90 per cent to about 20 per cent.
On the surface, this is a good thing. Canadians spend $219-billion a year on health care, including about $10-billion on home care and, as consumers and taxpayers, they deserve to get value for money.
While we like to preach the gospel of value-for-money, we don't measure it well – the ultimate irony being that expensive bureaucracies have been built to ensure home-care agencies are lean and mean.
VON had many disadvantages in a competitive marketplace – first and foremost that it never provided just home care to its clients. It delivered hot meals, made friendly visits (especially to veterans), ran adult daycare programs, provided respite care to families, visited new mothers and babies, did flu shots at home and countless other little things that never had a place in the accounting ledger. Some were covered by government payments, but many were not.
The VON supplemented its funds from government contracts with charitable donations. It had more volunteers (9,000) than staff (6,000).
VON also paid its workers a decent, living wage. The work force – mostly nurses and therapists – is unionized, salaried and they have benefits, including a pension plan.
In the brave new home-care industry, piece work is the norm, meaning nurses get paid per visit, and few have benefits, pensions or stable employment. It is also in the interest of workers (and employers) to get visits done quickly, and cram as many as possible into a day.
While this is a cost-effective business model, anyone with a loved one in home care knows that there is little continuity of care.
The relationships that are so important to intimate acts such as health-care delivery to frail seniors living at home are virtually non-existent.
When you have a strict business model, when all that matters is the much-vaunted bottom line, none of that gets counted.
The real tragedy in VON's unravelling is not that another home-care business is biting the dust (after all, there are hundreds more out there) – but that the "old-fashioned" way of delivering care – taking the time required to talk and listen to patients and treating them as people, not "units of service"; for example, not just changing their dressings, but feeding them and filling the fridge – is falling by the wayside.
With VON's collapse, we have a home-care system that may be more efficient – at least in theory – but one that has less heart.