Time to make aged care accountable.
Accountable to who?
To citizens and their communities
Please support our campaign to make this happen
Aged care has been a mess for over 20 years. At that time, the for-profit aged care industry persuaded governments to abandon reforms that they did not like and instead hand aged care over to them. They and their supporters have led the system ever since and government has done what they wanted.
A Royal Commission into Aged Care finally revealed the widespread neglect and abuse of vulnerable citizens that developed during this period. It has been hidden from us for far too long.
Industry groups responsible for this are trying to once again, steal the reform agenda from under our noses. They dominated proceedings at the Royal Commission and are lobbying government to support the sort of changes they want.
These changes are primarily to protect industry’s interests and their control of the system. An industry-led system is not what is needed to permanently stop the abuse and neglect occurring in aged care.
Government has shown that it can no longer be trusted. It’s time for citizens and local communities to take control and insist that industry be held accountable to them for the care given to their fellows and for how taxpayers' funds are being spent. This is what we mean by a community-led system.
In the words of Professor Joe Ibrahim when giving evidence to the Royal Commission:
“If we do nothing, then the people that will pay the penalty is everyone in this room. And so if no one wants to do anything, then the system that we accept now is what awaits us."
Who is responsible?
We need to look closely at those who are responsible for the abuse and neglect, see what their track record is, and what they are trying to do now. Can they really expect us to trust them again?
What has been happening in this industry-led system?
In 1997 government took aged care, which had previously been a largely community-led service based on our concern for one another, and handed it to a market that had very different concerns. They needed to compete to make money by keeping costs down.
Staffing requirements were removed and the number of staff and their skill levels were left to the market to determine. How money was spent and how care was provided was in confidence. Failures in care were not tracked, recorded or published.
In the absence of regulatory requirements staffing guidance has been provided by marketplace financial advisers and not by academic research.
Government wanted them to keep costs down and it did everything it could to help them do that. For the last 22 years we have had an industry-led aged care system.
Changes in 1997
- A market: The sector was turned into a competitive market and a policy that promoted increased competition and marketisation. The for-profit sector was strongly supported and the nonprofits persuaded to operate in the same way.
- Accountability abolished: Accountability was abolished for how money was spent, how much and where profit was taken, and for staffing numbers and skills.
- Staffing: By 1998, all remaining staffing requirements were removed and it was left to government's industry-friendly accreditation (regulators) to decide whether there were sufficient staff.
- Probity requirements removed: Probity regulations in health and aged care protected citizens by vetting new participants to be sure that they were “fit and proper” and could be trusted not to exploit residents. In 1997 government abolished federal aged care probity regulations restricting ownership, replacing them with an industry friendly ‘Approved Provider’ process. This opened the sector to all and sundry and the welcome mat was laid out. There was no mechanism for assessing owners. Any Tom, Dick or Harry who had enough money could buy nursing homes and appoint managers to run them the way they wanted.
- Approved Provider process: The Approved Provider process that replaced probity provisions does not have the power to examine owners. Owners who buy an existing provider, and so come to control the purse strings, no longer need to seek approval. All that is required is that managers they appointed to run the newly acquired subsidiary, referred to as "key personnel", do not yet have a criminal conviction.
Any criminal or company that has harmed it's customers, can buy a company already owning approved facilities without seeking approval, and then appoint managers to do what they want them to do. Owners can appoint managers to do their bidding, provided those managers do not have a criminal record. An owner could require them to squeeze care in order to increase profits.
[Remarkably, even the Royal Commission's new probity recommendations for providers, do not apply to the probity of their owners. Doing so would be seen as interfering with the operation of the market and so a challenge to the belief in free markets.]
- Goodbye regulation, hello accreditation: Carefully designed regulation was abandoned and replaced with an industry-friendly process known as 'accreditation', designed to assist and not police. Accreditation largely assists providers to regulate themselves. It has enabled government and its supporters to take control of the information the public receives, limit publicity and make unsupported claims. It helped to conceal the steady decline of staffing and care in a deeply flawed system.
Greater and greater focus on the market ever since
Over the years repeated efforts were made to ‘improve’ this market. These were guided by multiple reviews and reports from the Productivity Commission, accounting giants and business consultants. Industry figures were given senior positions advising government and one was later put in charge of the regulator. The more the government relied on the market, the more the system deteriorated.
In 2000 industry bodies and their supporters formed the National Aged Care Alliance to advise government. They worked closely with the labor government in developing the 2012 Living Longer Living Better (LLLB) reforms that further increased the problems in the sector.
In 2014 the coalition government appointed several representatives from the sector to a central policy making committee, the Aged Care Sector Committee. This created the Aged Care Roadmap, which made it even more market-led, the Red tape reduction program, which reduced regulation, and then adopted a policy of competitive consolidation, which put much more pressure on care. The rapid deterioration that followed saw the ABC Four Corners exposure of widespread neglect in 2018 and the calling of a Royal Commission.
Betraying our trust: Our previously involved communities were pushed aside. We have had no choice but to accept the market’s control of our aged care system and trust them. They have responded by betraying us as they squeezed the system for profit and then concealed the consequences.
False information and public relations to garner support: To gain our support and entice our elderly citizens into facilities where they have been neglected and abused, they have showered us with glowing images of happy seniors leading idyllic lives. Government have supported this deception and joined with them in boasting to us of a 'world class' system with a 'world class' regulator to protect the elderly. The general public have been systematically deceived.
Whistleblowers: This powerful industry was not going to tolerate those who exposed what was happening.
Staff who have spoken out about what was happening have been fired for doing so.
Families who complained about care have been barred from visiting their relatives and even silenced by threats of legal action. Researchers who described what their research revealed have been attacked and discredited.
Residents and families soon feared retribution and nurses feared for their jobs. Few were prepared to speak out. Good motivated staff were unhappy and went elsewhere.
Far from 'world class': Failures have been so bad and have occurred so commonly, that those responsible must have known what was happening. Yet, for the last 22 years we have been told that we have a 'world class' system and a ‘world class’ regulator. Failures were 'isolated or due to a few bad apples.
Both government and this industry have deceived us repeatedly over the entire 22-year period. Incredibly they still expect us to trust them and are asking for our support. We must never allow that to happen again.
What are government and industry doing now?
It is clear that the free-market policies and the ideas on which they are based have not been abandoned. In spite of many useful recommendations by the Royal Commission, they have left us with a market-led aged care system that is under pressure to make money. This is even though an Australian study has just confirmed that competition does not improve aged care and that the more competitive for-profit providers staff more poorly and provide inferior care to the nonprofit and government providers.
Policies responsible for this failed system were left unaddressed and unchallenged. As a result, citizens and communities have not been given the power to hold providers of care accountable.
Both major political parties and industry know the system is a mess. They both want this hot potato back in the cupboard with their other skeletons as soon as possible because there is an election on the horizon. They will opt for a quick fix to get it out of sight again and then reclaim their credibility.
Urgent action is certainly needed, but we need to fix this system now and not apply more patches. We need a path to a permanent solution where the primary concern is the welfare of those being cared for. That means moving from an industry-led system to a community-led one.
An industry-led public relations strategy: Instead of acknowledging their culpability and consulting with us, industry has rallied to form a new group called the 'Australian Aged Care Collaboration' (AACC). It is planning to reclaim industry’s tarnished reputation.
Their members are lobbying behind the scenes and meeting with politicians across Australia. Their interest is in preserving the general structure of the present system, not changing it.
Government too, is showing no signs of changing its aged care policies. It is still looking to industry to lead the reforms. As Minister Colbeck has so clearly shown, it is still unable to accept that its policies are fatally flawed.
Asking the public for support: The AACC has launched a marketing blitz to persuade the public to support the quick fix wanted by the industry. As part of their campaign, the AACC has prepared a report titled "Time to care about aged care". This describes the Royal Commission's findings and the inadequate funding by government.
They are trying to shift their share of the blame to government and in doing so are hiding their own responsibility for neglect and abuse.
Their campaign website and social media presence 'Care About Aged Care' is asking the public to sign a petition to their elected members supporting industry. Many signing the petition would be unaware of what they are really supporting.
They are still deceiving us and we must call that out urgently.
Industry’s responsibility for the many failures: The marketised system created in 1997 was industry’s system.
Industry were the driving force in this policy. They put pressure on government and they designed the new marketised aged care system created in 1997 together.
They have been at the table every time it went wrong and a new set of 'reforms' was implemented. The one thing that was not challenged was the belief in the infallibility of unrestricted markets that industry and government shared. Policy did not change.
The one thing industry still do not want is to give independent local citizens a greater say over aged care in their communities, but this is exactly what is needed.
Should we be angry?
We have every right to be angry but that does not help anyone. They are not all rogues. In spite of their behavior many of these people were well intentioned and believed in what they were doing. They believed so strongly that they developed blinkers.
This has happened many times before, in many societies and social systems. It has been extensively studied by interested social scientist and is well understood. These scientists have been trying to warn us but we have not been listening. It’s a complex area to explain.
What we do need to understand is that when this situation develops these groups of people will blindly adhere to their beliefs and try to do the same things by simply moving the pieces about. That does not fix the problems.
To make real change, their power to control others and persuade them has to be taken away first. In the past this has often required a revolution. In a democracy and in a market it is much easier.
These systems depend on a balance of forces with the most important holding centre stage. When they fail we need to make them work by structuring them so that happens. In a community service it is the community itself that should be the most powerful and be placed centre stage.
Once enough citizens realise what is happening and how they have been deceived, they can use the power they have to vote for people who will do what they want. They can give their money and custom to those who will work with them in giving them what they want and reject those who don’t.
What can we do about it?
A long-forgotten principle: As caring citizens and communities, we have a non-delegable responsibility to see that our parents, grandparents and fellow citizens are well cared for. That responsibility has been taken away from us and we must take it back.
Those providing care are our agents doing it on our behalf. They need to work closely with us and be directly accountable to the communities they serve. We cannot delegate this to government but we expect those we elect to support and help us. Aged care must be driven by the need for a community service and not commercial opportunity clothed in deceptive words.
Its time to wake up and act: United we have the power. We can insist that aged care becomes community-led and that both government and the market support us with their expertise and are accountable. To survive politicians and commercial operators must stop selling us snake oil and instead work together with us to do what is required.
In the words of Professor Joe Ibrahim when giving evidence to the Royal Commission: “If we do nothing, then the people that will pay the penalty is everyone in this room. And so if no one wants to do anything, then the system that we accept now is what awaits us."
We need your support
You can support our campaign for a community led system by:
- Understanding what a community-led aged care system would look like and what would be expected from citizens and then completing our survey to show your interest and support.
- Sharing a link to this page
- Reaching out to politicians and letting them know you want to be heard
- Sharing your views and experiences with us
- Sharing our posts and messages widely and on social media platforms, eg, Twitter
- Forming local community groups to pursue these objectives.
A community-led aged care system
A community-led aged care system is a system where community takes overall control of and responsibility for care and:
- works closely with the market and government at a community level, drawing on their expertise.
- selects providers it needs and wants and puts those who don't meet their expectations out of business.
- persuades other members of their communities to vote against governments who don’t do what is required to provide good care to elderly citizens.
A community-led aged care system empowers communities to hold both providers and government to account and prevent more neglect and abuse in the future.
In such a system:
- Government decentralises management and integrates aged care through independent regional and local officials. It employs people from within the communities served to carry out its activities.
- Community groups drawn from local communities become involved in aged care. They utilise the time and resources of healthy retirees and other interested volunteers. They play an important role in many of the basic support and oversight processes of aged care, like complaints resolution.
- The community groups would work closely with government employees and with local providers. They would meet regularly and the community participates in decisions.
- Each community participates in planning the sort of services and facilities needed in their community and does not leave it to those who just want to build something that is profitable rather than suitable.
- It works with regional managers in contracting the construction of facilities that are needed.
- It participates in the selection and licensing or contracting of providers to deliver the care required.
- The community would be in a position to decide whom they will trust to provide services to their parents, grandparents and then themselves before they are licensed or contracted.
- The Community would be actively involved with local providers in watching over care, handling complaints and addressing issues so would know what was happening.
- The community would be in a position to easily replace a provider who fails to deliver the care they require. The current system would be restructured to make that possible.
- The community organisations would have a central body representing them and putting their views to central management, government and bodies representing other groups.
If you would like more detail about how this might work, please read the web page explaining why such a system is needed and how it would operate. We illustrate how it will empower communities to hold both providers and government to account and prevent more neglect and abuse in the future.
Learn more: Creating a community-led aged care system
If you are time-poor but want to support this campaign, please take our Accountability Survey. If we are to succeed in making aged care more accountable to citizens and communities, we will need strong support from them. .
Understanding community-led aged care better: We have prepared a number of more in-depth web pages where we explore these topics. You can look at the short summaries provided further down the page. If they ring a bell with you, please use social media to engage your friends.
These summaries support our argument that the Royal Commission has failed to fully address the deep problems in the system and the power imbalance created by them. The many good recommendations they made will not work for long because they have not addressed the real causes. We explain why citizens need to take further action to address these issues by pressing for aged care to be community-led rather than market-led.
These linked pages are for those who would like to:
- gain a greater understanding of what has been happening and why we should replace the market-led system that the Royal Commission into Aged Care and the government still want. and
- understand why it is so important that we challenge this and insist that it be replaced with a community-led system and why there is only a narrow window of opportunity to do so.
These topics are summarised briefly above each of the collapsible panels below, linked to pages that explore the issues in more depth.
This section below, describes the basis of our Accountability Report. It shows how industry is trying to seize the high ground and the role they played in designing and supporting this failed system.
Accountability Report: Challenging the Australian Aged Care Collaboration
The report directly challenges and refutes the claims made by the Australian Aged Care Collaboration (AACC) in its report and its campaign.
It describes the difference between market and community led systems then briefly explains the claims made in the AACC report and their denial of culpability.
It describes the extensive involvement of the industry with government in every step of the development of this system. This was their system and nothing was done without their approval. They supported all of the reforms that did not work and failed us all.
Unhappiness in the workplace: The page then describes how the different approach by an industry-led aged care service creates cultural conflicts that lead to unhappiness among staff and so poor care.
Provider types and the AACC: The page describes the different types of provider, and the organisations that have formed to represent them. It describes the way that religious and charitable providers responded and adapted to a market-led system and competition from those who were there to make a profit. It shows how much they have changed as they adopted the same patterns of thought..
It describes how industry group ACSA and the religious providers have now become the public face of the AACC.
Learn more: Check out our Accountability Report
This section below, describes the root cause societal problems responsible for failure in aged care as well as many other vulnerable sectors. Aged care is only one of many failures and part of a wider problem.
Why society has failed the elderly: The consequences of policy failure
On the linked page we outline the root cause, the social disease, responsible for many market failures in vulnerable sectors. This disease has developed in society as its relationship with markets and government was changed. Aged care is simply one of the worst affected.
The page describes the changes that have occurred over the last 30 to 40 years in society, in governments and in markets and in the way they relate to one another.
Civil society, once the bedrock of our democracy and the protector of our rights was for some strange reason seen as a threat to both our democracy and our rights as individuals. Markets and government have pushed it aside and formed an alliance that puts them above the society they belong to and should serve. Civil society has a vital role in democratic societies. The huge consequences of doing this have been ignored.
The many warnings that predicted what would happen were ignored and the many systems that have failed have been treated as isolated problems. Attempts are made to treat the symptoms in each system while the root cause, the underlying disease in society has been ignored. Untreated it has recurred after claimed ‘reforms' and spread to other sectors which have failed (eg. banks to aged care).
A success story: Doctors in Australia recognised the problems in the 1990s. By uniting they were able to challenge government policy and then put those health care corporations that transgressed out of business. An example that we are urging our communities to follow.
Why it is never challenged: The page explains why it was so impossibly difficult for the over 30 inquiries into aged care carried out by believers in the market-led system to challenge the market-led system they had spent their lives working in and even discuss the possibility of a community-led one. We think the Royal Commission had the same problem.
As a consequence, symptoms were treated sometimes with good palliation but the disease persisted and soon recurred.
This is a longer and more in depth page, which quotes from the believers who adopted the system as well as those who saw the consequences, warned and were ignored. Most should get the gist of it.
This section below, describes our premonitions, our warnings and then our experience as we tried to persuade the Royal Commission to look at root causes and then make structural changes that empowered communities - the important things they did not do.
An opportunity missed: Aged Care Crisis attempts to persuade the Royal Commission
On the linked page we set out our position on the issues by summarising the arguments made on the web page ‘Why Society has withered’. We conclude that the root causes lie in problems that have developed in the relationship between the different components of society. Society and government have been eroded and become subservient to markets.
We suggest that the Commissioners have not addressed these issues and as a consequence they are treating the symptoms of the social disease responsible (palliation) but not the disease itself which is likely to recur in time.
Our submissions: We were worried that a government that saw this primarily as a market and not a community service, would appoint credible market experts as Commissioners to address market issues rather thanindividuals with wider expertise who could address this as primarily a failure of a community service. We describe our unsuccessful effort to influence this.
In our submissions to the Royal Commission we challenged the Royal Commission’s failure to confront the deeply flawed policies and the philosophy that supported it
We blamed the failures on a market-led system that placed the market above the society it claimed to serve and denied them a role. We urged a decentralised but centrally mentored and integrated management and oversight structure.
Our submissions stressed the need for greater community involvement and control, and made suggestions for doing this. We include short quotes from some of our submissions and letters to illustrate the arguments we made.
The Commissioners did not challenge or analyse the role of the market-led system or discuss any sort of community oversight or control. We conclude that while the final report made many important recommendations it did not address these root cause issues and it remains market-led.
This section below, we analyse the Commissioner's main recommendations and give an overview of its report.
An opportunity missed: Analysis of the Royal Commission Report
On the linked web page we summarise the main features of the Royal Commission’s final report released in February 2021.
The Royal Commissioners recommended many sweeping changes in a seven-volume report and, if fully implemented by government, there will be many beneficial changes. Critically it aims to enshrine the right to good quality care for every citizen as a fundamental principle in a new Aged Care Act. It is going to be very costly.
They do recommend a greater regional management presence and encouraging feedback from recipients of care and communities. There is not much specificity in their proposals.
Regional managers may not be sufficiently independent. Citizens and Communities will not be empowered. We think that it does not go far enough and unless we seize the opportunity and build on it, the power imbalance and the powerful perverse incentives in the system will not be adequately addressed.
We document the many issues covered and the recommendations, many of which we agree with. There are problems in others. We make comments and indicate where we think a community-led system would have been preferable and would work better.
It is not what they recommended as much as what they failed to address and did not recommend that concerns us. The report made a very good job of identifying the symptoms and its measures should give good palliation. But the underlying disease persists.
It remains a market-led system eager to forget the past. Communities will not have the power needed to hold anyone accountable. The same perverse commercial pressures will gnaw away at the increased regulatory effort they recommend and find ways around them.
We worry that we will see a recurrence within 5, 10 or maybe more years. We believe that if the community unites and presses hard enough for a community led system this can still be accomplished within the overall structure of the new system.
Update - May 2021: Financial Transparency Inquiry
Aged Care Crisis made submissions to the Inquiry into the proposed Aged Care Legislation Amendment (Financial Transparency) Bill 2020. We gave evidence at a public hearing of the Senate on 14 May 2021. There are two documents which are of more interest and relevant:
Response to Questions On Notice
We were asked to respond to Questions on Notice and our response has been published.
- First we were asked how effective both the transparency legislation and the government budget support for aged care would be?
We explain why the legislation and budget will help but fall a long way short of the major structural changes needed. We quote from others who have written about this.
- Secondly we were asked what could be done about the webs of related party transactions that most big aged care providers now employ?
We explain the central role their use by private equity and other large groups have played in diverting money from care to profits in the USA, the UK and Australia. This has been at the expense of the residents who needed care. This is a problem where regulation has failed but which a community-led system would address.
Learn more: Aged Care Crisis response to Questions on Notice
Analysis of aged care as a failed complex social system
This analysis was supplied to the senate committee and has been published.
We apply a model used by research into the failure of complex social systems to aged care. This shows how strong pressures introduced into complex social systems can make them unbalanced causing them to fail and do harm.
They then go through repeated cycles of failure. When they fail, vested interests responsible for the strong pressures fight back to seize control and government managers respond by centralising ineffective regulation and oversight. The next cycle starts again.
This is the second time that we have had a major crisis of neglect and abuse in aged care. The first was in the 1980s when planned sensible reforms were abandoned as the angry community lost interest and vested interests regained control of government policy.
The studies show that there is a crucial point soon after the failures occur when vested interests are weakened and community movements can make real change. The cycles of recurrent failure have been successfully broken when strong community pressures were applied before the vested interests regained power.
Management of the systems has been decentralized into local regions and these local managers have worked closely with local communities and community organisations as well as the businesses involved. This restores balance.
Those vested interests have rapidly regrouped this time and community is being fobbed off with more snake oil. That window of opportunity is rapidly closing. If we don't come together and take strong action, it may well take another 20 years before there is another opportunity to fix the real problems in aged care and restore that balance between the interests of the community and those of the market.