The article by Anne Martin-Matthews and Joanie Sims-Gould is a very welcome piece of research within the home care sector. There is limited research available in regard to the home care, and even less of that research focuses on the unique challenges of delivering services to clients in the home setting (as opposed to home care research that addresses questions of a more clinical nature such as falls prevention). The authors have framed an important question by inquiring about the key issues in delivery and receipt of home support services. Many of us in the sector believe the issues to be self-evident; however, the advantage of this work is that these issues were examined from multiple perspectives.

While the study was conducted in the Vancouver area, British Columbia, the issues identified are common to home care delivery across the country. This is despite our desire to believe that each area is unique and that home care delivery presents its own set of unique challenges in our various geographies.

The discussion regarding recruitment and retention is a refreshing one in that it goes beyond the usual arguments of remuneration and scheduling (which are well documented as significant challenges) to examine the issue of intrinsic benefits to working in the home care sector and how capitalizing upon these benefits might present an additional strategy for home care employers. In Ontario, managed competition has often been cited as a primary cause of the recruitment and retention challenges within the home care sector. Interestingly, according to these authors, similar issues with recruitment and retention exist in British Columbia seemingly independent of the fact that British Columbia does not share Ontario's managed competition approach to the provision of direct client services.

Another area that was examined in this study and is of considerable practical application to the home care sector is the issue of the dynamic tension between client needs and assigned tasks. This issue gets to the heart of the gaps that currently exist in our policies and funding approaches to the provision of home supports. Client needs in quantity, breadth and scope greatly outstrip our ability as a sector to meet those needs. The result is both unhappy clients and frustrated workers, who want to do more but are restricted by the limitations of the system.

Also of practical application, but even more challenging than the lack of fiscal and human resources, is the difficulty matching available resources to client needs and preferences. As a sector, we do reasonably well at matching resources to clients' needs but just do not have the human capital to adequately address preferences, particularly as they relate to time-specific visits.

While not specifically mentioned in this study, waiting lists for personal support services are another key indicator of home care system limitations, and they present a major challenge in meeting client needs. Home care waiting lists exist in many provinces and are a growing reality in many areas across Canada as the demand for services continues to outstrip the available fiscal and human resources within the sector.

On the topic of allocation of limited resources in the home care sector, an article by Don Guy (2002) in Healthcare Quarterly pointed out that while most Canadians support medicare funding for home care, only 46% believe that that funding should include supports for personal care and grooming. The vast majority of the support Canadians expressed for home care funding was limited to nursing, medication and physician supports in the home. It would therefore appear that the needs of key home care populations, such as the frail elderly, for personal support services to remain in the home setting are not well understood by the general taxpaying public.

Martin-Matthews and Sims-Gould conclude that solutions must consider multiple perspectives (employers, workers and clients) and be based on a shared understanding of the issues. This is undeniably true and a valid recommendation. The suggestion to "lead by example" was a little vague and, as such, it is difficult to understand how one might go about the practical application of this recommendation; however, the comment that employers, worker and clients hold the keys to improvements is a sound observation. The final conclusion was that relationships are crucial to the development and understanding of the system and to making the system work. While this conclusion is certainly true, it seems that there could have been more substance behind this recommendation to really benefit those trying to ensure system improvements.

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