Paving the Road to Long-Term Care Reform in Ontario: A Retrospective

The Broader Policy Context

In the first year of their second mandate, the Ontario Liberal government received three pivotal healthcare reports from the Ontario Health Review Panel (Chaired by Dr. John Evans), the Panel on Health Goals (Chaired by Dr. R. Spasoff), and the Minister’s Advisory Group on Health Promotion (Chaired by S. Podborski).  Collectively, these reports advocated for a broad definition of health, refocusing the provincial system on community care, health promotion, and disease prevention. This momentum led Premier David Peterson to establish the Premier’s Council on Health Strategy (PCHS) in December 1987.

Chaired by the Premier with the Minister of Health as Vice-Chair, the Council adopted the World Health Organization’s (WHO) definition of health, acknowledging the social, economic, environmental, and lifestyle factors involved. The PCHS proved to be a powerful forum for shifting policy toward a “population health” approach that considered key areas that play a critical role in contributing to health, other than the traditional health care system (e.g., housing, income, social supports). While the Council’s formal reports were not released until 1991, the continuous involvement of the Premier, various Ministers, and senior bureaucrats ensured these ideas permeated government activities well before then. This interweaving of the bureaucracy with the Council also ensured that this realignment in thinking endured beyond election cycles.

Long-Term Care as a Priority Based on Principles Guiding Reform

In 1989, John Sweeney, Minister of Community & Social Services (MCSS), was given responsibility to lead the reform of Long-Term Care (LTC). This decision reflected the vision set out in the Office for Senior Citizens’ Affairs White Paper (A New Agenda),[i]as well as the advice of the Premier’s Council and the opinions of the World Health Organization (WHO). The prevailing view was that health status is determined by social factors, requiring a move away from a strictly medical treatment model. The goal was to shift from institutional reliance to community services with strong local involvement.

The reform of Ontario’s LTC system was guided by seven draft principles developed in 1989 emphasizing efficiency and cost control. These were designed to:

• Reform the funding system to focus on individual needs.
• Support informal caregivers.
• Encourage the use of the most appropriate, cost-effective services.
• Prioritize care in a person’s own home.
• Establish a single, integrated admissions process for both LTC beds and community services (such as home care).
• Strengthen the role of local communities.
• Ensure affordability through an appropriate sharing of costs.

The work of the Premier’s Council had an enormous influence on these principles. The Health Goals Committee emphasized the social environment’s impact on health; the Health Public Policy Committee noted the limits of medical treatment alone; and the Health Care System Committee presented a plan to make community services an equal partner with the institutional sector. Finally, the Integration and Coordination Committee recommended devolving budget and management authority to local levels while keeping legislation and standards at the provincial level.

In June 1989, to turn these principles into policy, Minister Sweeney formed an Inter-Ministerial Steering Committee led by MCSS. For the first time, senior staff from the Ministries of Health, Social Services, Seniors’ Affairs, and Disabled Persons, Cabinet Office and the Management Board of Cabinet sat at the same table to develop a unified plan. It was chaired by an assistant deputy minister whose responsibilities included both health and social service mandates. Their goal was to streamline services by early 1990. A provincial government task force focused on long-term care reform was also established, reporting to the Inter-Ministerial Steering Committee, and was charged with reviewing the province’s long-term care and related support programs, as well as the results of numerous, reports, program reviews, and research articles. Unlike later governments, where policy became more politically controlled, the bureaucracy led much of the work of the task force helping shape the reform process.

This collaboration resulted in establishment of a new, integrated provincial management structure – the Division of Community Health and Support Services within MCSS. This new division included staff from both ministries. By merging long-term care and support services with community-based health services, the government created the “intellectual scaffolding” for future reform.

Investment in Reform: The 1990 Budget

The April 24,1990 Peterson Budget was a watershed moment for the community support sector. The budget included significant funding for the comprehensive reform of long-term care with a plan to create new, community-based service access agencies to allow people to find the help they need in one place. To begin with, the budget addressed the looming demographic and fiscal pressures of the decade:

Despite the federal government’s decision to reduce support for cost-shared programs, Ontario will ensure that vital services are not jeopardized… Governments must implement plans now to ensure that adequate and efficient services will be available [for the increasing number of elderly and persons with disabilities].

The budget committed new investments up to $410 million by the middle of the 1990’s (later expanded to $646 million by the subsequent NDP government) to transform the sector. This investment sought to modernize social programs through a change in thinking toward in-home support and streamlined access. Key targeted community investments are highlighted in Figure 1.

Figure 1: Summary of Targeted Investments (1990 Provincial Budget)

The budget also announced the government’s intent to introduce a consistent level-of-care funding system for homes for the aged and nursing homes.

Strategies for Change

On May 30, 1990, Minister Charles Beer released a landmark policy document Strategies for Change – Comprehensive Reform of Ontario’s Long Term Care Services.[ii] This report outlined an incremental approach, building a coherent system on the foundation of existing services. Community-based services would be emphasized to enhance self-reliance and to assist people to live in their own homes and communities.

The report included a revised set of the 1989 draft principles to explicitly reference individual dignity, independence, and consumer choice, and laid out six essential service components as a framework for LTC reform (Figure 2). These strategies were part of a shared vision to create a fully developed, coordinated service system for the long-term care sector.

Figure 2: Strategies for Change: The Six Essential Service Components:

1. Coordinate Access to Services (Service Access Organizations (SAOs)): Designed to provide a simplified, “one-stop” entry point for services, removing the conflict of interest inherent when direct providers also manage access.
2. Integrate and Consolidate In-Home Services: Focused on enabling independent living.
3. Enhance Community Support Services: Consolidating meals-on-wheels, transportation, and maintenance services into a coordinated provincial framework.
4. Determine the Relationship Between Specialized Services and the Long-Term Care and Support Services System: Providing expert geriatric assessment and treatment.
5. Enhance Support for Informal Caregivers: Recognizing and supporting the family caregivers who are the backbone of the system.
6. Reform Policies for Long-Term Care Facilities: Fully integrating nursing homes and homes for the aged into the broader reform strategy.

The Strategies for Change document also prescribed three key enablers to achieve these strategies. These included: establishment of an equitable and flexible funding approach for community services; introduction of a balanced co-payment policy for consumers; and involvement of local communities in service planning.

The Legacy of the 1990s Redirection

Because Strategies for Change was released in May 1990 – just months before the September election – the immediate stakeholder response was a blend of cautious optimism and election-year skepticism. Seniors’ advocacy groups welcomed the policy shift toward “aging at home” and the promise of “Service Access Organizations.” This “One-Stop-Shop” model addressed long-standing grievances regarding the province’s fragmented maze of services. While the NDP and Progressive Conservatives agreed with the principles of community-based care, they dismissed the timing as an election ploy and questioned the feasibility of the funding model in the face of a looming recession.

Despite the Liberal defeat in 1990, the momentum for reform proved remarkably resilient. The incoming New Democratic Party (NDP) maintained the trajectory established by the report, and in 1991, Minister Zanana Akande formally confirmed the redirection, committing the necessary financial resources to sustain the shift.

However, the implementation of these ideals faced a significant hurdle: the tension between social and medical models of care. Despite the vision incorporated in the Strategies for Change report advocating for a “social model,” the Ministry of Health eventually dominated the implementation process under the subsequent NDP and Conservative governments taking over full responsibility for long-term care reform. This led to an increasingly “medicalized” version of home care, where essential personal supports and “homemaking” services (e.g., cleaning, meal preparation) were gradually phased out in favor of strictly clinical nursing care. Furthermore, the original vision of building a comprehensive “system” of long-term care was compromised by a series of piecemeal reforms.

Nevertheless, the Peterson government’s 1990 budget and the Strategies for Change report succeeded in establishing the structural framework for long-term care reform in Ontario. This work constructed a new philosophy of care that recognized the home as the primary site of dignity. A close examination of the six essential service components in the report confirms that, forty years later, these priorities remain at the forefront of policy discussions.

While progress has been made on several fronts, these strategies have not yet been advanced in the truly integrated fashion envisioned in 1990. As Ontario continues to pursue “integrated care” today, the vision serves as a persistent reminder: the challenges of interdependence and the need for a seamless continuum of long-term care services have still not been fully achieved.

Conclusion: The Long Road to Integration

The Peterson era (1985–1990) represents a fundamental pivot in the history of Ontario’s social policy. By establishing the Office for Senior Citizens’ Affairs (OSCA) and championing the Strategies for Change report, the government did more than just balance a budget; it introduced a new “social contract” for the province’s aging population. This era marked the transition from an institutional-heavy model to a philosophy that recognized the home as the primary site of dignity.

However, the legacy of this period is one of unfulfilled integration. While the 1990 report provided the structural framework for modern reform, its full implementation was hindered by two recurring themes in Ontario health policy:

1. The Medicalization of Care: Despite the Liberal and subsequent NDP governments’ rhetoric regarding “social models,” the Ministry of Health’s eventual dominance shifted the focus away from “homemaking” and personal support toward strictly clinical, nursing-based care. This effectively narrowed the scope of what it meant to support a senior at home.
2. Systemic Fragmentation: The “One-Stop-Shop” vision – the single point of entry designed to eliminate the “fragmented maze” – has been reinvented by successive governments under various names (CCACs, LHINs, and HCCSS). Yet, the “navigator” role envisioned in 1986 remains a work in progress, often compromised by piece-meal reforms rather than systemic overhaul.

The 1986 vision outlined in A New Agenda, and the 1990 Strategies for Change roadmap remain strikingly relevant in 2026. As Ontario continues to grapple with “hallway healthcare” and an increasingly complex demographic shift, the lessons of the Peterson era serve as both a guide and a warning. They remind us that true integration requires more than just a coordination of services; it requires a sustained commitment to the social determinants of health and a recognition that a senior’s quality of life is found in the community. Forty years later, the road to long-term care reform is still being paved, guided by the very principles of independence, choice, and dignity.

— This article was co-authored by Charles Beer

Bibliography

 Primary Government Documents

Government of Ontario. (1986). A New Agenda: Health and Social Services Strategies for Ontario’s Seniors. Toronto: Office for Senior Citizens’ Affairs.

Government of Ontario. (1987). Health for All Ontario: Report of the Panel on Health Goals for Ontario (Spasoff Report). Toronto: Ministry of Health.

Government of Ontario. (1987). Health Promotion Matters in Ontario: A Report of the Minister’s Advisory Group on Health Promotion(Podborski Report). Toronto: Ministry of Health.

Government of Ontario. (1987). Toward a Shared Direction for Health in Ontario (Evans Report). Toronto: Ontario Health Review Panel.

Government of Ontario. (1990). Strategies for Change: Comprehensive Reform of Ontario’s Long-Term Care Services. Toronto: Ministry of Community and Social Services.

Ontario Ministry of Treasury and Economics. (1990, April 24). 1990 Ontario Budget: Delivered by the Honourable Robert F. Nixon. Toronto: Queen’s Printer for Ontario.

Secondary Sources

Baranek, P. M. (2000). Long term care reform in Ontario: The influence of ideas, institutions, and interests on the public/private sector. (Doctoral dissertation). University of Toronto.