The aged care system in Australia is broken and no longer works for citizens. It has been broken for a long time. It is trapped in a thought bubble from which it cannot escape, so is incapable of helping itself.
As far as aged care is concerned, the political system is also broken. To survive, politicians must compete for the attention of a disenchanted community, one that has disengaged from aged care. Aged care politics is captive to vested interests that are powerful and perceived as credible. They are skilled users of the media. In the current climate politicians feel they can't (or won't) take risks and aged care is a hot potato that has been pushed into the too hard basket.
“The idea exists [among bureaucrats and politicians] that RACFs are just homes. That is clinical nonsense”
“It’s a failure of bureaucrats and politicians. This issue doesn’t get the attention it deserves and in the current political climate I doubt that it will”
Associate Professor Craig Whitehead (President of the Australian and New Zealand Society of Geriatric Medicine)
Given the adversarial nature of the politics of this area, the commercialisation of the RACF industry and familial neglect for some older people, I think we have more hope of seeing pigs fly than reasonable reform.
Comment by Professor Gerard Gill (General Practice)
Source: Aged care “broken” MJA Insight 7 April 2015
Summary of this web page
This web page shows that many who have experience or are in a position to know are as concerned as I am about aged care. They recognise that the failure to confront the issues in aged care is largely due to a political stalemate. The page explains who I am and why I feel I can contribute. It looks at the contrasting perceptions of the performance of aged care by politicians and providers when compared with that of those who have examined the system carefully.
A major cause of this is that data measuring care and quality of life is not collected and the available information comes from industry and government. It's time to resolve this issue by collecting information.
Professor Maddocks, a palliative care specialist and I have both suggested a community based organisation to control and manage aged care in each community. This is compatible with new 21st century patterns of thinking about citizens involvement in decision making in a democratic society, and about the care of citizens in need. This should be the product of a community debate conducted by and within the community.
I argue that aged care is a failed market because there are few effective customers. My focus differs from Maddocks' in that my focus is on the community rather than doctors and builds on his idea by using it to create an effective customer to make this market work.
I argue that there is some urgency as the government has introduced Consumer Directed Care (CDC) for home care using a competitive market model. It plans to extend this to nursing homes. While CDC is an advance, it has been organised by the industry and the opportunities to exploit vulnerable people in this sort of market place are much greater. It would be much safer if it were supervised and controlled by a local community hub.
Who I am and why I am contributing
Many will think it is presumptuous of me to criticise aged care when I have no experience of aged care myself. I feel justified in doing so because I have spent a life practising medicine and have had experience with dysfunctional political and medical systems. I have been a whistlebower in health care and have studied vast numbers of documents describing problems in health and in aged care internationally and in Australia. I have made a number of submissions to aged care inquiries and have lobbied governments and strongly criticised them.
My experience is that outsiders often see more clearly than those inside the system and that they should speak out. I see the system very differently to the aged care establishment and think that I can make a useful contribution. I believe that aged care and the direction it is taking in Australia is something that we as a community should be very concerned about.
If you want to know more about me and why I am making this contribution I have elaborated here: Why I am writing these pages
Politics, perceptions and data
Rob Oakeshott held the balance of power in the Gillard government's hung parliament. He and Tony Windsor tried to change the way party politics worked. Oakeshott speaks from experience describing how politics is in the pockets of wealthy businessmen, who also fund large advertising campaigns promoting their ideas to the public. This is one of the reasons our politicians cannot act in our interests. I will examine others later in Parts 4 and 5. Oakeshott bewails the extent to which political donations have destroyed our democracy.
He claims that the influence of big money undermined the sort of democracy that he and other independents tried unsuccessfully to bring to Australia during this period. While he does not talk about aged care, what he is saying is important for an understanding of why aged care is broken and not serving Australians. As I will show later, the aged care industry has been either in the pockets of government or in bed making policy together since 1996.
... Our key decisions for the future of Australia are now being outsourced at a level never before seen. Parliamentary democracy is going through its own sort of privatisation. Bigger dollars come into the party coffers at exactly the same time as less and less of the necessary work gets done. We are trapping ourselves ..."
Source: Rob Oakeshott: How big business hijacked parliament - The Saturday Paper 8 Aug 2014
There is no prospect of politicians making real change until a failure to do so carries a much greater risk for them. Like other countries that depend on a market system to provide vulnerable aged care, our government is "rejecting the case for a new human rights treaty" for the aged at the United Nations. Could that be telling us something about how this market in these countries works in the real interests of the frail elderly?
Different understandings: Currently, there is an enormous gap between what is seen by politicians and the providers of aged care when contrasted with the views of those who have looked closely at what is actually happening.
This is well illustrated by a recent article published in ABC News. This gave the views of an academic studying aged care and an industry representative. It was followed by a typically angry response from the industry representative in their online publication claiming the observations described by an academic in this article are "inaccurate and outrageous", "shoddy research and trashy journalism"; that it was "unsubstantiated scaremongering" and that she had "not done her homework".
- Questions raised over how national changes will impact aged care sector(ABC News, 31 Jul 2014)
- Academic scaremongering with unsubstantiated claims(ACSA news release, 31 Jul 2014)
Lack of data: A core problem in the system is that objective data that would tell us what is actually happening is simply not being collected. What we want is a system where exactly what is happening is clear to everyone, and where we can draw our own conclusions.
In my view, it is time for society to re-engage with aged care, to take charge of the agenda and create a system that works. Society is in a position to insist politicians comply.
Lets stop complaining and do something instead
For the last 17 years, those who have been aware that the system is failing have been complaining and then expecting someone else to do something about it. That has not worked. Its time for us to start publicly debating about what is wrong, deciding what we want done and then insisting that it gets done.
To set this process in motion these pages contain my assessment of the problems and my suggestions for doing something about it.
The idea for a Community Aged Care Hub
Professor Ian Maddocks (Senior Australian of the Year for 2013), recently proposed the development of "Community Aged Care Hubs" built around "residential aged care facilities".
I have been writing submissions to aged care inquiries for a number of years urging that the whole aged care process and its regulation be moved into local communities. These local communities would play a central role in controlling and coordinating the operation of aged care in each local community, representing and acting for vulnerable older customers.
The word hub so accurately sums up what I have been urging that I am going to use it. It will also reflect my strong support for Professor Maddocks proposal, with which I largely agree. These web pages are intended not only to support his ideas strongly, but also to build on them.
- Big challenge requires bold thinking: Maddocks (Australian Ageing Agenda, 11 Jul 2014)
I want to throw the idea open and get people debating. I want people from all sectors of society to come up with their assessment of why things are failing and their ideas about how we can do better.
Starting the debate
The CEO of ACSA (the body representing not-for-profit providers of aged care), has also called for debate and asked the community to engage.
... Adjunct Professor Kelly said his biggest hope for the next five years was for the community as a whole to engage in the conversation about how to care for older Australians with the respect that they deserve ... "
Source: Engaging in a conversation - Australian Ageing Agenda, Newsroom, (and on YouTube) 8 Sep 2014
The problem is that ACSA has not been receptive to criticisms. It has aggressively attacked and sought to destroy the credibility of its critics. Discussion means engaging with your critics and addressing their concerns. ACSA wants community discussion, but only on its terms and it wants to set the agenda. I can understand why they behave like this, but believe it is very counterproductive.
We, the community, are the customers and the recipients of care. We need to set the agenda and decide what and how we are going to talk about this. The problem for us is that we have been excluded for so long, that most of us don't have the knowledge and a grasp of the issues any more so are seriously disadvantaged. We get disjointed soundbites on television. We need to assemble them to see and understand what is happening.
This website is an attempt to address all this by providing a source of information and a place where we can bring our views together. It puts up a proposal for consideration. Like ACSA, we want a conversation, but a constructive one on our terms not theirs. We welcome their input to our discussion because we are the community and they are there to serve our community. They can't exist without us and we can't do without them. But we want them to address our concerns and they are not doing that.
Experience: I have worked in different countries, different environments and different health systems. I have spent 20 years looking critically at serious problems in health and aged care markets, where people were too often harmed instead of helped. More recently I have looked more closely at aged care in Australia. I have made a number of submissions to inquiries over the years.
I have come to the same approach to the problem as Professor Maddocks, but from a different direction. I have some different ideas as to how a hub would work to create a better system. It should work to both protect our aged care system from the problems I have seen, and improve the care given and the lives of the elderly in the way Maddocks suggests.
Doctors and the community: Professor Maddocks sees the medical profession as the parties creating and building the hub. I also have a medical background, but I have been disappointed in the way my profession has disengaged from aged care and failed to confront what has happened constructively. Instead I have looked to the community itself to establish this hub, and hopefully bring doctors back into the sector. The involvement of both is critical.
I suggest that you look at what Professor Maddocks has suggested and then see how that fits into the sort of system that I envisage. The suggestions I have added to his proposal are based on proposals I made in submissions to inquiries into the complaints system in 2009, the accreditation system in 2009, and in more detail to the Productivity Commissions Inquiry "Caring for Older Australians" in 2010. I wrote the first draft of these web pages in 2013.
I am going to describe what I am suggesting first and will then give an outline of why the different suggestions I have made, and the involvement of the community, are important. I will follow with a more detailed analysis and explanation.
The Centre for Welfare Reform: Since writing these pages I have become aware of the work of the Centre for Welfare Reform in Birmingham, UK. Its ideas are gaining a lot of attention. Some of the centre's analyses of the social policies adopted in the last 40 years add considerably to what I have said on these pages and I am generally in agreement. As I point out in Parts 4 and 5 in the Solving Aged Care section, aged care is only one victim. It is one of the sectors which have suffered most from what one of the authors describe as ‘the hollowing out' of local communities.
The sort of hub I am proposing is a step in the same direction as that advocated by the centre. The hub I am suggesting in aged care attempts to address what is wrong in the sector, by re-engaging and rebuilding the "hollow communities" by re-involving civil society in the affairs of the community and the nation - in this instance aged care. By addressing the issues in aged care, we contribute to addressing the larger problem.
The intention of the proposed hub is to move the main focus of aged care into local communities and create the context for a "bottom up" innovative social force in the sector. We must avoid throwing out the baby with the bath water. We do not want to replace what we have with something based on another belief system either left or right. We need a community that looks critically at the good as well as the bad in what we have now, and then builds realistically on that.
What I am suggesting is a way of getting from where we are now to a situation where the community have the knoiwledge and are in a position to be involved in evaluating ideas and deciding where we should be and how our aged care system should operate. This seems to be very much what this centre is trying to achieve in other areas.
Aged care is trapped in 1990 patterns of political thinking that do not work for aged care and because of this is unable to move on. We need a system that is flexible and responsive so that we do not spend another 17 years locked into a belief system that sometimes does more harm than good. We cannot accept a situation where the information we need to understand what is happening and address the problems is either not collected or hidden from us.
Nursing homes: I am going to continue to use the term "nursing homes" rather than the politically correct and sanitized "residential aged care facilities". This is because good nursing is essential for good care and these are the residents' homes.
Problems in these facilities are most commonly due to a lack of good nursing, and to pressures in the system that make the facilities more like a warehouse than a home. Cynics talk about "wrinkle ranching".
What I am suggesting is not confined to nursing homes. It applies as well to care in the community.
The principles of 'How do we solve aged care?'
The real and effectual discipline which is exercised over a workman is that of his customers. It is the fear of losing their employment which restrains his frauds and corrects his negligence.
The interest of [businessmen] is always in some respects different from, and even opposite to, that of the public ... The proposal of any new law or regulation of commerce which comes from this order ... ought never to be adopted, till after having been long and carefully examined ... with the most suspicious attention. It comes from an order of men ... who have generally an interest to deceive and even oppress the public
Source: Quotes from Adam Smith, (18th century father of economic theory) - Wikipedia
It is increasingly clear that aged care is an example of a failed market. This is a serious and increasingly common problem in capitalist societies. It occurs most commonly because customers (euphemistically called "consumers" in these sectors) are vulnerable, lack information and do not have market power. They are ineffective as customers, not only because they are unable to protect themselves from exploitation, but because they cannot hold those responsible to account.
Examination of markets where customers are ineffective shows that, in this situation, aberrant cultures develop that give rise to practices and policies that ultimately harm society and its citizens. For the purpose of this proposal and my arguments I am going to call these cultures "culturopathic".
As Adam Smith indicated over 200 years ago, an effective customer is essential for a market to work and that the community needs to carefully evaluate proposals made by business interests. Our community has been deliberately kept in the dark, does not have the information it needs and is so distracted by other issues in their busy lives that they have disengaged from aged care.
This problem has developed in capitalist societies over the past 40 years because the lessons of history and the basic conditions needed for a market to work have been ignored. None of the many inquiries and reviews into the aged care system since "market reforms" were introduced in 1997, have been prepared to accept that there was anything fundamentally wrong with the market system as it had been applied to aged care.
Submissions drawing attention to problems and failures in this market have been downplayed and ignored. Once we accept that the system is broken, and that this is not the only sector where this is happening, then we have no choice but to critically examine the underlying structure of the system we are using in all of these sectors.
That we are dealing with a failed market has been the elephant in the room for the past 17 years. In my view the evidence for this is now overwhelming.
I stress that this is not an attack on capitalism but a criticism of the way its fundamental principles have been ignored.
Professor Maddocks' proposed hub will be very useful but it does not address these problems. The extensions to his hub that I am proposing seek to address these problems by, in addition:
- creating an organisation or hub in each community that will have the information and market power to be an effective customer; and
- creating contexts and working relationships between the community and providers of care in each community that will generate cultural change in the sector, reinforce community values, and restore trust and trustworthiness. This is essential for a sector serving vulnerable members of the community.
These proposals are congruent with government policy requiring organisations to partner with customers and communities. They provide a mechanism for doing so in a way that creates an effective customer, one who can contribute from a position of strength.
While we have a strongly competitive market mechanism for providing aged care, any solution that does not address these two issues is doomed to failure and the problems in the system will continue to grow.
There is some urgency to get the community involved because industry groups have been pressuring the government to introduce Consumer Directed Care. This was done in July 2015, even though same thought that the industry was not yet ready to do so. It is being done in ways that will benefit the industry but are likely to put vulnerable seniors at increased risk.
The idea is appealing and has considerable merit. It is the way that it is being done that is so worrying. This will expose vulnerable seniors to the full force of the competitive market, without addressing their increased vulnerability under the new proposals. You need to understand the background to this and I explain that briefly below.
How policy is planned in aged care: One of the major problems in the aged care system is that a group called National Aged Care Alliance (NACA) has been working closely with our aged care ministers over the years and has acted as adviser to them. They have formulated the policies that ministers have followed. They have been responsible for much of the system we have now and for the proposed changes.
NACA is comprised of members of the aged care industry, and a very limited number of aged care senior organisations. They have been working closely behind the scenes with government in planning and restructuring aged care the way they want it. We only hear about developments when the government is ready to sell them to us.
Other larger seniors organisations are out of the loop and the wider community have been excluded. I believe that our largest seniors group National Seniors and also the Combined Pensioners and Superannuants Association (CPSA), representing retirees, withdrew from NACA years ago. This was because the conditions of membership limited their ability to speak freely and criticise the policies that the majority decided on.
The community were to be kept out of the debate and these groups were not prepared to go along with this. Even at that time the seniors groups were a minority and industry groups dominated. The seniors groups that withdrew from NACA would have been aware of the direction planned for aged care by industry and the government. Because they were a minority they would have been forced to become a part of any decision the majority wanted and would be prevented from criticising even if they disagreed strongly. This was unacceptable to them.
CPSA has been a particularly strong critic of NACA, of COTA the seniors group that decided to remain a member of NACA, and of NACA's policies and close relationship with government. National Seniors has also strongly voiced its concerns about the problems in aged care and about Consumer Directed Care, but has been less confronting. A wedge has been driven between the seniors groups, with the NACA membership on one side and the larger seniors community on the other. CPSA asserts that COTA acts as the consumer voice for the industry and government. This division has undermined the strength of the seniors lobby and their effectiveness. This is only one of the situations where politicians and interest groups have undermined our democracy in order to drive their political agendas and restrict debate.
Current position: The Abbott government was particularly sympathetic to what the industry wants. This is the system their party created in 1997. Abbott was minister for health (and aged care) during that period. What they are now planning sounds very attractive but the way they are planning to introduce these changes does not address critical faults in our current system and these are likely to be exacerbated.
I believe that it is critically important that we as a community look at our system, decide what we really want and then insist that we have a say in what and how changes to the system are made. This secretive behind closed doors planning of our future is undermining our democracy and must be stopped by citizens.
Pressure to move quickly: The government's popularity was at an all time low because of its strategy of making decisions without discussing with the community. Its prospects for re-election looked shaky. Abbott's replacement by Turnbull has dramatically changed this and there may be some hope. They may now be more receptive to criticism and alternate points if view.
A February 2015 article Sector agitates for further aged care reform revealed that NACA and its supporters were agitating for the government to press ahead with what they want as quickly as possible and we can understand why. There is a large pot of gold at the end of this rainbow for many of its members and it is coming out of our pockets. Labor might not be as enthusiastic. Some of those involved argue that the system is nowhere near ready to introduce CDC yet and there is a lot amount to be done first.
There is much that is desirable in what is suggested but we, as a community, need to be satisfied that it is really desirable, is done in a way that works for us and that the money is well spent. This is not happening at present. What I am proposing will ensure that we as concerned citizens will be at the table in future when aged care changes are being planned. We will be in a position to make our own proposals and get what we want and need.
I believe that Consumer Directed Care (CDC) should be introduced in close cooperation with and managed wholly or jointly by the Community Aged Care Hub that I am proposing for each local community.
All of the Australian seniors' groups would have input into this. Planning discussions about this would not be restricted as has happened with NACA. Without community involvement and oversight, the planned CDC places elderly residents at a significant risk of being misused.
In a long 2012 article and comment section which exposes the difference between COTA the seniors group that remained with NACA and the others, Michael O'Neill from National Seniors explains the problem with Consumer Directed Care.
Some advocates warn that a free-market approach is unsuitable for aged care, because unlike normal markets, consumers of aged care are especially vulnerable:
... The push around consumer choice or a greater role for the consumer in the marketplace in some ways is a bit of a nonsense," says O'Neill, of National Seniors Australia ...
... (Consumers are) - - at a great disadvantage when dealing with sophisticated companies that are adept at navigating the system. --- (as are) families confronted with big decisions at a time of great stress ..."
"The consumer's power in this market will be very, very limited," says O'Neill.
Source: How Our Twilight Years Are Ripe For The Picking - The Global Mail, 22 Feb 2012
Consumer Directed Care is only one of a multitude of problems in aged care that the proposed hub is intended to address. It also seeks to move beyond the divisions that have paralysed the seniors groups. These have made seniors a divided, conflicted and ineffective stakeholder in the system.
What I believe is needed will require strong support to achieve. There are powerful commercial and political interests involved and it will need strong and concerted action from all of us. To do that we need to decide what we need and want and then make that absolutely clear to our politicians.
Note: A strongly competitive "self-regulated market" is not my personal preferred "ultimate solution", but correcting the flaws in the way this competitive market is currently being applied in aged care is the most practical way to address the problems created and provide a framework from which we can move forward.