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International reviews - Political and aged care problems are global

As Camilleri indicates, the problems extend across all countries trapped in the current patterns of thinking. Multiple sectors are affected. On 25th May 1996 Professor Stephen Leeder, an eminent Australian doctor, wrote in Australian Medicine that "business thinking" which he likened to "mad cow disease" had worked itself from the top down into every vein of our society, "compatible or not".

At that time, a fatal chronic untreatable neurological disease of cows had spread to man and had spooked the world. It was characterised by strange delusions early in its course.

The USA and the UK led the way in applying this mad cow thinking in the 1980s. Between 1996 and about 2007, I wrote vast numbers of pages containing data about the consequences in the USA including 64 pages on aged care in the USA alone. There is an overview here but if you need to look at it please only scan this page quickly and don't follow links else you will never get back here.

US civil society is unable to challenge the economic rationalist free market paradigm in any way as it is deeply embedded in their culture. So although community has rallied, citizens have concentrated on punitive action through the courts and that simply has not worked well enough to make a big difference. Problems are on-going.  The UK however, does not have that heritage. Community groups are vocal about what has happened there.

The material in the sliders below gives some idea about what is happening and how those involved are thinking about it.  In both countries, there are challenging videos showing what is happening in some nursing homes.

The initial slider sections below, are about aged care in the UK:

UK: Reviews and documentaries

Reviews: The review article quoted below describes what is happened in the UK. It is interesting for what it says about aged care in that country, as well as what it omits. This is revealing because it is written by someone within the aged care industry and illustrates industry's ideas about a solution.

In seeking answers, customers and community are simply ignored - a giant blind patch. But it is well worth reading. The article describes what it thinks is needed.

Like Dr Mykyta in Australia, the report wants aged care to be part of the health care system and not a poor orphaned cousin. Almost everything it wants to do is good, but it has a cargo cult approach looking to government and industry to do it.

As Camilleri shows, while competitive market pressures and economic rationalism continues to drive politics and the aged care system, it simply won't happen. Perhaps we Aussies could tell them to "Get real mate! Give your citizens a kick in the butt and tell them to get out there and take control. Engage with your community and talk to the Centre for Welfare Reform. Work with your community and help them do all this themselves"!  Government and industry won't.

A unique inquiry into the state of the care home sector for the Joseph Rowntree Foundation (JRF) today calls for sweeping change to ‘inject humanity' back into care homes, with personal relationships put at the heart of how they are run and regulated.

The current blame culture, bureaucracy and business model have contributed to the 'permanent sense of crisis' the sector finds itself in today and needs to be urgently changed. The inquiry argues human relationships and caring needs to be central to the system and the sector - replacing the impersonal and insecure culture that currently shrouds the whole care environment.

Regulation should be more than inspection. Regulation should look at pay and working conditions, staffing levels, mission, commissioning practices and transparency of tariffs, in order to improve the quality of care. To be good, care homes need to work in a functional system.

Source: Fundamental change needed to end 'permanent sense of crisis' in UK care homes Joseph Rowntree Housing Trust, 26 Oct 2014

Aged Care documentary: In the section about the USA, I have included links to a graphic confronting video program. But the same problems seem to exist and the same sort of videos illustrating what happens in aged care are appearing in the UK. A 2014 BBC Documentary titled "Panorama Behind Closed Doors Elderly Care Exposed" showing similar footage and looking at the problem is no longer available on U-tube.  An article in buzzfeed describes this report in some detail and one of the homes is run by BUPA. 

In spite of the tight economic situation in August 2014, BUPA announced "a  4% rise in UK profit to £61.3 million" and it is interesting that much of this increase came from home care which is also said to be in crisis.  But "including international operations, notably Australia and New Zealand, group revenue was up by 7% to £4.8 billion".   One wonders if there is any relationship between increased profitability and the reported failures in care in the UK and Australia.

Home care: Home care, it seems, is also in serious trouble and a crisis is predicted.

Lest there be any doubt that the domiciliary or homecare sector is in crisis, consider this. The biggest provider in the £6bn market was already up for sale. Now its book value has been reduced by its present owners to nil.

Saga, which bought Allied as recently as 2011, is retaining three small homecare businesses for private clients. But it is seeking to sell the main operation that tenders for council contracts and has formally discontinued it for accounting purposes, though it continues to trade.

The acute fragility of the market is starting to register – if not with politicians, at least with their officials

The CQC has just appointed a former banker, Stuart Dean, to lead on its new duty under the Care Act to oversee the financial health of the 43 biggest companies in the care sector. His role is to head off any repeat of the collapse of the UK Southern Cross care home group in 2011. Given the special plight of domiciliary care businesses, let’s hope their files are top of his in-tray.

Source: If homecare businesses collapse, the health system will be in real trouble  The Guardian, 19 May 2015

(Note: Southern Cross was the UK's largest nursing home group.  It was bought by a US Private Equity Group that stripped it of its value while retructuring then sold it leaving it vulnerable to the first downturn in the economy. Southern Cross went bankrupt.)

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UK: Care standards - Care Quality Commission (CQC)

The fundamental standards for nursing homes set out by the UK's Care Quality Commission (CQC) are clearly often not met. The reports and information available on their website are however, far superior and far more useful than those available from our Quality Agency here in Australia. Here is an example.

Visits are more frequent and unlike Australia, reports are not restricted to 3 or even 5 yearly planned formal accreditation visits. All visits and their findings are available going back up to 5 years so that a facility's track record is accessible.

But as in Australia and the USA, there are many claims that this is simply not working in the face of the pressures in the system. On 22 February 2015, BBC news reported that Thousands of complaints made about elderly care in England and that "Some 14,888 claims about the welfare of care home residents aged 65 and over in 2013-14 were reported to 74 councils, - - - ". They give an example and point to understaffing in the homes and in the oversight body as the problem claiming that this is due to underfunding.

Company bosses from BUPA, a UK global nursing home operator were summoned to a meeting with Scottish health secretary There had been a number of problems in care homes in Scotland and in one, police were investigating deaths.

Following numerous failures in care and intense criticism, the CQC has issued guidelines for family and management setting out guidelines for grannycams (CCTV  videocameras to see what is happening).  It is interesting that a union survey has found that 'three out of five residential care workers feel "relaxed" about visible cameras being installed in care homes'.

The whole idea of government monitoring standards is now being attacked and discredited in the UK.  This is all relevant to us because our Accreditation regime is also sadly even more deficient, if better than nothing.

The horrific standards of elderly care exposed by the BBC's Panorama on Wednesday must have put paid to any idea that it is possible to inspect quality into a service – a concept that has anyway been made redundant by companies and service industries since management guru W Edwards Deming denounced the idea in the mid-1960s.

The folly of relying on inspection as either a marker or maker of quality has since been confirmed by a distinguished chain of management academics. The Panorama programme highlighted the futility of inspection in care homes, yet the NHS has persisted with a quality regulator for 14 years: the Care Quality Commission has been exposed as little more than a spectator in the delivery of safe care.

The programme revealed that CQC inspectors had approved the home where savage abuse took place. The CQC's chief inspector, Andrea Sutcliffe, said: "I'm shocked and really angry about what Panorama have found." An outsider would be shocked; insiders know the appalling conditions in many CQC-registered homes.

The CQC is irrelevant in the landscape of care, and as a solution exists only in the minds of ministers with an eye on the newspapers

Quality is made in the boardroom, and if companies won't take their responsibilities seriously, the law should help sharpen their focus. A fit-and-proper-person test for all directors is good enough for football's Premier League, and it must be good enough for your granny in a care home.

Inspection hides poor practice, and companies become more concerned with the regulator than with residents and relatives. Sensible investment, sharing best practice, highlighting what works and leveraging on success – that's what delivers for patients. Inspection never will.

Source: Care home inspections are futile  The Guardian, 1 May 2014

I’ve seen care homes turned around and the system of regulation and inspection isn’t the way to do it

The whole social care sector is forced to prioritise the regulator’s demands over the needs of its clients, and they really aren’t the same.

The costs of regulation are enormous

But the biggest cost is not financial: it is the loss of initiative, leadership, and professionalism, and the devaluation of personal caring relationships - - - . Such friendship is neither compliant nor measurable, but it is the essence of good care.

Sources: After 50 years in the sector, I know the CQC rarely improves social care  The Guardian, 22 Apr 2015; A contribution to the British Medical Journal - Margaret McCartney: The Care Quality Commission is not fit for purpose  BMJ, 12 Dec 2014

When a whistleblower who had been a CQC inspector spoke out about its failure to act, the CQC admitted that it was the fear of litigation that stopped it from being effective,

Rebecca Prideaux, said regulators were failing to take proper action even after she warned of appalling failings in care, and claimed reports often omitted some of the most damning failings.

Ms Prideaux said poor care routinely went unchecked because staff at the Care Quality Commission are given inadequate training.

Source: Former CQC inspector says elderly are being left to suffer - The Telegraph, 20 Sep 2013

The head of the Care Quality Commission (CQC) said it has too often “backed off” from making attempts to close unsafe homes and “tended not to fight back” when was legally challenged.

David Prior, chairman of CQC, made the disclosures as the regulator vowed to change its approach, to be “much more robust” in taking on poor providers of care.

Source: We failed elderly because we were too scared care home owners would sue us, watchdog admits - The Telegraph, 9 Aug 2014

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UK: Financial woes

It is claimed that cost cutting in the UK has left nursing homes short on cash and private equity in particular is struggling.

Private Equity

Private Equity ownership has been a major problem in aged care in the UK. The US Private Equity Group Blackstone is alleged to have left the UK’s largest nursing home, Southern Cross, weak and vulnerable so that it subsequently went under. Four Seasons, nother large private equity group, is struggling and may go under or simply vacate the sector. Care has suffered as a consequence.

Elderly residents at nursing homes run by Britain's largest care provider could have to be rehoused unless the firm's funding crisis is resolved soon, it has emerged.

Four Seasons Health Care is understood to have begun an emergency review after losing £25 million in the three months to June.

The company looks after 20,000 patients at 450 nursing homes. According to reports, loss-making residences could be closed unless Four Season can obtain more funds from investors or the Government.

But a larger disposal of its properties might prove trickier. The entire care industry now faces a greater funding pressures than in 2011 and other companies could decide against buying Four Seasons homes if they cannot see a way of making a profit. In such a scenario, residents may be forced to fall back on NHS facilities.

Source: Four Seasons funding crisis: thousands of elderly care home residents face uncertainty The Telegraph, 30 Aug 2015

See also:

A study in which leading Private Equity managers were interviewed, is revealing of the strong commercial pressures generated in the Private Equity sector:

Nurses salaries

Salaries in nursing homes in the UK are so low that the community and some councils have tried to force the providers to pay a living wage. A National living wage requirement is planned for 2016.

 - - - work has become synonymous with poor pay, zero-hours contracts and long hours. Yet while a growing number of homecare providers seem to be improving pay and conditions, care home providers have stayed deafeningly silent.

Source: Why do so few care homes pay staff the living wage? The Guardian Feb 3, 2015

Executives have already admitted that plans to introduce a national living wage next year will put at risk "hundreds" of homes run by private care operators.

In a letter to George Osborne, Four Seasons joined Bupa UK, HC-One, Care UK and Barchester in warning the extra costs would mean "thousands of older people could be left without a home".

Source: Four Seasons funding crisis: thousands of elderly care home residents face uncertainty - The Telegraph, 30 Aug 2015

Retirees hock their homes

As in Australia, neoliberal policies are placing an ever greater cost on people who cannot afford to pay and who are using the value of their homes by having a charge placed on their estates so they pay when they die.

The report also revealed that many people will face care bills well in excess of their pension pot as the average time spent in a care home has increased drastically in the past decade.

Data disclosed to insurer LV= from councils across England show that more than 19,000 retirees have had a charge placed on their home by their local council in the last five years.

This means they have elected for the council to cover the cost of their care and claim the money back from their estate after their death.

Source: Thousands sign 'pay when you die' care deals - The Telegraph, 13 Aug 2015

Home Care

ITV news describes the problem that providers of home care are having in providing care because of the underfunding. They did a survey of 305 responders (out of 500 asked) who were contracted by local authorities. They indicated that “Their responses revealed a shocking lack of confidence about their ability to provide good quality care at the prices local authorities are now willing to pay.” The full article is linked below.

UK: Trapping the unwary

In a highly competitive market the pressure to keep your nursing homes full of people who pay well is very strong. One way is to flood the media with good news stories so that they drown out the bad. PR firms make their money by doing just that for the care homes. The quote below is from a PR firms web site. You need to read the whole of it to see the strategy. They are building traps for the unwary. 

'James' is a family member looking for a home for a parent:

Then James selects a home to visit. Will it be yours? You must make certain it is.

So write up those ‘good news stories’ now. Even better if you can get eye-catching photos to go with it.

Get it right and EVERY single piece of ‘good news’ you produce has a FIVE-FOLD PR and marketing value:

Have you got our free guide on how PR builds the reputation – and sales – of your care provider?

Source: Care home PR – secrets revealed - Springup PR: Media Insiders delivering big results, 24 Aug 2015

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UK: Criticism of privatisation

There is increasing frustration with privatisation in the UK and many are speaking out about its failures. There was an article by Cat Hobbs, the founder of "We Own It", a new organisation that aims to be a voice for public service users and public ownership.

There are several links to follow and some comment. Privatisation isn't working. It's time for a public service users bill. It is on The Guardian website (5 Aug 2013). It calls for legislation to address the problem. Those interested might like to look and see where it goes.

"THE PRIVATISATION OF THE CARE INDUSTRY; ITS OWN NEMESIS": Ian Cresswell from the Community aged care group “Your Voice Matters” tracks the path that health and aged care in the UK has taken following the drive to privatise health and social services that commenced in the Thatcher and Reagan eras.

In the UK, "privatisation" is used to describe free market solutions because it was introduced into a socialised system. In other sectors they talk about "new capitalism". The article shows how the pursuit of these objectives has ultimately led to the sorry mess that is aged care in the UK. This article is interesting because we have followed that same path but started later and its not as bad as this - yet.

Community anger about privatisation: A community group - the NHS Support Federation, has material about privatisation on its website. So concerned is it, that it has set up a separate website NHS for sale.  This is a large, extensively researched website examining the extent of privatisation by big local and multinational organisations. 

It examines the adverse impacts this has had in some detail.  It examines the track record and background to many of the large UK and international corporations which are contracted by the NHS and the problems that have arisen. The list includes Australia's Ramsay Healthcare, SERCO, HCA (the US giant with a record of massive fraud) and several others.  This is a good site for those wanting to look at the problems with privatisation in the UK and in health care more generally.

Some support for this comes from an inquiry in the UK which "concluded that some big hospital groups are making excess profits. HCA was singled out for what was considered to be its dominant position in the capital - - - ."  HCA is a US giant with a history of massive fraud settlements in that country.

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UK: The community collecting information

As in Australia, there are families who have had bad experiences and who have looked around them. They have realised that what they have experienced is industry wide.  Some have become whistleblowers. They have started looking at what is happening, collected information and put it on the internet.

To ordinary citizens scattered around the country, these events seem isolated but when they are collected together, the story they tell about what is happening, and how commonly, is telling and very worrying. Similarities and patterns appear. They show what is happening and why.

One such sight is a Facebook page Your Voice Matters.  They are pressing for CCTV monitoring in all nursing homes.  Another excellent website "The Bank of Home Care" to which a lot of attention had been given particularly to ownership issues has recently been taken down without explanation.  We wonder why?

Ireland has problems too. The Mirror reports people wasting away and dying as carers look on in Irish nursing homes because there are no staff to feed the residents. The food is so poor some won't eat it and there are so few staff that the food soon gets cold. Staff whistleblowers indicate that they have complained to managers but that nothing is done about it.

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UK: Auctioning off granny - the ultimate indignity

In order to save money by placing the frail elderly in the cheapest places, some regional authorities in the UK have quietly gone further than anyone else in turning the elderly into a commodity - a parcel (profit body that will generate a profit after they have been purchased) that is traded on eBay type web sites.

Details of the senior's age and care needs are put onto the website and local nursing homes then bid to provide that person's care. The authorities are able to reduce their spending by up to a fifth by getting competitive bids and then choosing the cheapest available service.  They even boast about it.

This is an invitation (perverse incentive) to the providers to cut staffing and the other costs of care to win the bidding. The reports are here and also here. Even some in the USA are shocked and disgusted at the 'cattle markets'.  The US press reports that at least 12 UK councils are doing this.

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UK: Positive message - Targeting Dementia

As in Australia, there are mixed positive and negative messages coming from different sectors. The Prime Minister in the UK is mounting a massive project to research dementia and to train people to care for others with dementia. There is an overview from government on a press release "PM launches next phase of Britain’s fight against dementia" where there are links for those who want to follow this.

As in Australia, the current UK government has been pushing an aggressive privatisation campaign and been criticised for it.

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UK: The UK in crisis December 2015

Social Services in the UK system are under pressure. Government is not prepared to pay companies the money they need to be viable in the system that has been created. Care is collapsing and no one is coming up with answers. There is a growing volume of material analysing how the UK arrived at this impasse but not too many suggestions as to how to get out of it. While Australia is different in many ways we have, and still are, pursuing similar policies and there is much to learn.

Care home bankruptcy has become such a serious problem for local councils that the Quality Care Commission keeps a list of difficult to replace providers and facilities whose financial health it monitors. It warns the local authorities if those they use are at risk.

The UK’s largest nursing home chain, private equity owned Four Seasons is desperately shutting nursing homes in order to stay afloat. This must be because no one wants to buy them. This is happening in the face of an aged care bulge which like Australia the UK must meet.

In the UK as in Australia it is so often only after whistle blowers notify authorities that problems are identified. While data collection is far superior to our quality agency oversight by periodic visits from government bodies like the CQC have not worked. This is why I argue that a local oversight presence is essential. Multiple problems were found in the home described below.

A politician who tried to help a constituent hit a brick wall when trying to have failures in care addressed. As he discovered ‘Of the 700 establishments most recently inspected, a staggering four in ten have been rated as either “requires improvement” or “inadequate”. The purpose of any regime of inspection and regulation must be to drive up standards. These figures alone suggest that the current system simply isn’t working’. ‘Despite a raft of reforms in recent years, the CQC is not fit for this particular purpose’.

A review of the changes that have occurred in the provision of social services in the UK comments that “We have ended up with some pretty shocking services in social care because at the end of the day the market was about driving down prices, which it has very successfully done.”

An article in The Guardian looks at the way this system, in which publicly funded care has been contracted to the market, has failed because government can no longer, or for some other reason won’t, fund the profits the market need to make. I realise that an alternate system which is not as dependent on generating profits would also suffer but think it might have more latitude and cope better.

An open letter to the new labour leader, Jeremy Corbett, examines the history and explores the failures in the provision of social services in the UK.

The article below explores what has gone wrong with social services in the UK. It seems that “funding issues now look to be threatening some of the central tenets of the (social services) act”. One critic believes that “the government has missed a golden opportunity not only to address an injustice but to make contact with the wider population and establish their care needs much earlier.

The comment that “one familiar ploy is to make the research fit the policy rather than vice-versa” should be very familiar to us in Australia as should concern that economic considerations are given disproportionate weight. One commentator indicated the “economic dimension is perfectly legitimate but it mustn’t trump the evidence from other sources.”

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NZ: Privatising Accreditation in New Zealand

Australia is now responding to our own problems with Accreditation by deciding to contract it out to the market.  New Zealand has a system of oversight contracted to the market.  It did not work either. 

The Government response to a Health Select Committee review of a damning Auditor General's report on rest home monitoring was tabled in Parliament today.

The 2009 report from the Controller and Auditor-General was scathing about the monitoring of aged residential care services in New Zealand and it criticised the previous Labour Government's handling of rest home monitoring.

"That report noted that the Ministry of Health struggled for years to ensure the quality and safety of rest home services and was particularly critical about a lack of action between 2002 and 2008," said Mr Ryall. "We have spent some time since the election dealing with this mess."

Source: Govt acts on rest home report recommendations - NZ Government website, 19 Jan 2011

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The slider section on the USA contrasts an insightful press investigation with a political hearing in California. The slider looks at the availability of data, informative books and at the relationship between health and politics. Then there is a link to a confronting TV documentary that is on YouTube.  This shows how bad it can get and then looks at why. There are lessons for Australia.  There is a vast amount of information about what happened in health and aged care in the USA and how bad it was up until about 2005 on the Corporate Medicine web pages that I wrote at the time.

USA: Some background in care

Recent analysis of problems: In the 1990s I remember reading reviews claiming that problems in aged care had been ongoing for over 20 years in spite of inquiries and multiple efforts to deal with them. Now almost 20 years later reviews of aged care like that just done in California are using the same 20 year figure to say the same thing. California is currently going through the process all over again. Little seems to have changed.

In November 2014 The Sacromento Bee, a paper that has been writing and exposing problems in aged care for at least 20 years, published a three series in depth analysis of aged care in that state Unmasked Nursing Home. They examine the many measures of care and staffing that are available in the USA and describe the poor quality of care as well as the way staffing is deliberately reduced and money funnelled away.

The articles document the large variation between different providers. They track the complex and hidden ownership structure to show how ownership impacts on care. They illustrate what can happen in an aged care sector without effective customers - one dominated by corporate providers monitored by ineffective government agencies.

It seems that the largest and most commercially successful owner seems to be the worst when it comes to caring for its residents. Resident's families are suing.  Regulators are involved and one of its nursing homes is facing criminal charges.

Extendicare is a Canadian company that does most of its business in the USA.  It was making headlines for all the wrong reasons in the late 1990s, usually for the record payments awarded by angry juries.  Fifteen years later its still doing it.

Extendicare, which owns 150 nursing homes in 11 states and denied any wrongdoing, was accused of inappropriate billing and providing inadequate care

Source: Nursing home chain agrees to pay $38M to settle government poor care claims Associated Press, News Medical, 10 Oct 2014

Government reports: The Senate Select Committee on Aging and Long Term Care in California released its report titled, A Shattered System: Reforming Long-Term Care in California on 20th January. I cannot pretend that I have done more than just read the executive summary and scan some of this large 211 page report.

It documents a fragmented organisational structure with a piecemeal and reactive approach to change. It calls for a long term plan and recommends legislative changes. It calls for better oversight and reporting, infrastructure for home care, delegation of tasks performed by nurses, investment to build infrastructure, engaging with federal authorities. It issues a call to action.

I studied the US aged system from the late 1990s to about 2004. Reading this report was groundhog day. I have seen this all before. The report fails to even look at the critical issues revolving round corporate ownership identified by the The Sacramento Bee newspaper and there is no thought of involving consumers.

Revealing, is that it does not make the complex ownership trail transparent, a key issue that the The Sacramento Bee highlighted.  Ownership was the key to what happened in nursing homes.  If they knew the real owner then potential residents would know the sort of nursing home their local one was likely to be. It is likely that the The Sacramento Bee knew what the senate eport would contain and why they did this investigation and published these reports. This complex paper trail has been the subject of criticism for many years.

The report acknowledges - but does not tell us about the real problems in the USA. It does illustrate the way they are handled using motherhood statements and proposing plans to show activity so keeping critics at bay. The way this is done is informative for us as our various reviews and reports over the last 17 years seem to have gone the same way as those in the USA.

Publicly available data: Unlike Australia, governments in the USA have not abolished the collection of objective information about care and staffing so although much is still missing there is considerably more information available.

The government run Nursing Home Compare web site allows the public to examine all of the data collected about any nursing home in the USA and there is similar information available for home care.

In addition, the entire data set is available to download so that researchers can evaluate the trends and relationships shown by the data and publich this. But it is the press, individuals and some academics, rather than government, that have collected information in the USA and analysed it.

The relationship between staffing and care (added Dec 2015): The USA has been more active in recording staffing levels and relating them to care than any other country. I am aware of articles starting in 1994 until recently - all saying the same things. Australia carefully avoids collecting this information and continues to make assertions and claims in the face of evidence.

As long ago as 2002 US authorities recommended a minimum of 4.5 hours of nursing care per resident per day because they had found that failures of care were likely below 4.1 hours and would be frequent below 2.9 hours. The extent to which US companies fail in meeting this is well known but with such a powerful lobby there has been little willingness to enforce it.  In Australia we simply don’t know what our staffing levels are and if we did we would not have any local data to measure it against.  Instead we continually have advertorials about innovations involving staff rotations that are claimed provide more for less staffing.  Until we actually collect data about failures in care and can prove it we should assume this is wishful thinking or commercial opportunism.

Nursing home agreements remove the right to sue:  Nursing homes in the USA are pressuring residents to sign away their right to take court action for damages and to arbitrate instead. But by doing that, they give up their right to use the discovery process to procure documents, to subpoena witnesses for depositions, and to secure sworn testimony as to the facts of the case. They sign at a time of stress when they don’t understand.

Late last year, Judge Jeffrey Sprecher upheld the family’s right to sue, finding the arbitration agreement "unconscionable" because it was presented to Brown at emotionally difficult time; consisted of long, confusing passages; improperly portrayed the deal as beneficial to all parties; and included a confidentiality provision that Sprecher said was "designed to bury all proof of bad things that may be alleged to occur in a nursing home."

Many of the arbitration agreements restrict a complainant’s access to records, as well as the number of depositions and witnesses. Some place limits on how much a party can recover in damages.

Source: Editorial: Nursing homes take away right to sue - The Des Moines Register, 19 Aug 2015

Books about health and aged care: There have been some excellent analyses of health. The first by Dave Lindorff in 1992, which included aged care, was "Marketplace Medicine: The Rise of the For-Profit Hospital Chains". At the time it was considered to be biased by the medical profession and other reviewers were not persuaded by the arguments.

The second book by two award winning New York Times investigative journalists Bartlett and Steele 12 years later in 2004 was "Critical Condition: How Health Care in America Became Big Business & Bad Medicine". It was graphic in its examples and definite in its analysis describing a situation well beyond Lindorff's predictions. In a page describing the role that financial institutions advising big health care corporations played in health care that I wrote in 2004, I included several quotes and comments drawn from this book. The same marketplace approach and political solutions were applied to aged care. Academics and newspapers in the USA have written extensively about aged care.

All of this material and a succession of scandals have resulted in a trail of inquiries and recommendations, yet very little has changed. The USA has a number of issues inhibiting real change that we don't have. The first is that a free market is integral to The American Dream and any attempt to criticise it or tamper with it is seen as anti-American and lacks credibility. The public will complain and act - but they will not challenge this basic tenet of the American way of life. As a consequence, the solutions that these analysts propose have not really addressed the issues they have identified.

Politics and the marketplace in health and aged care: The problem Australia also has, but not to quite the same extent yet, is the close interdependence between politics and marketplace, with a revolving door and financial support binding the political process to marketplace concerns and economic ideology. Well thought out and motivated reports can make recommendations but if they do actually result in action they have been modified and massaged to accommodate to a multitude of powerful interests.

In my view, if the recommendations of the Californian senate report are acted on, they may make limited improvements but it is also likely to be simply another placebo to keep critics of problems in care at bay. A whole new study of data in a few years time will be needed to show that the problems are still there, but by then everyone will have moved on and a new groundhog day will start.

In 2004 I wrote a web page Politics, Markets, Health and Democracy  about the close relationship and interdependence of politics and markets in the USA and the relationship of this to health and aged care. Little has changed and I think it is still relevant 11 years later. There are lessons there.

(Added Dec 2015) Like the UK the USA is also facing a “looming crisis in family caregiving” and there is pressure to make this an election issue. Of the candidates only Hillary Clinton, who has had personal experience of the problems is taking any interest.  It is interesting that the limited legislative changes that have been made focus on supporting a community solution and are not looking to the market for help.

The corporate aged care lobby, like that in healthcare is enormously wealthy and powerful. It is very unlikely that any government could make effective changes even in the likely event that this became an election issue and that this brought a political party into power. Australia is no different and that is why we need to develop another strategy.  That is why ACC have opened the Solving Aged Care debate and why I am writing these web pages.

A very confronting analysis: In the USA "grannycams" (hidden video cameras) are often used by families who are worried about what is happening to their families. There is a fairly recent very confronting video (be warned) on YouTube Fault Lines - Elderly Incorporated("Fault Lines investigates the business of elderly care, and what happens when corporations put profits ahead of care" - 20 Sep 2013).

Apart from some of the grannycam clips showing horrible abuse, there is nothing amateur about the video. It shows the same sort of video clips that contacts sent me in the late 1990s. It discussed the difficulty in detecting abuse and distinguishing it from illness and ageing by using external oversight and occasional visits as happens in Australia.

The video illustrates just how bad a strongly competitive and profit focussed aged care system dominated by large market listed chains and private equity can get. On "Part 5: Background to Community Aged care Hub" I describe how the conflicting paradigms (ways of thinking) in aged care cause people to become alienated - blunting their emotional responses and their ability to empathise and feel for others. They can respond by taking their resentment out on others or by amusing themselves by taunting them. Some of this is apparent on the video.

There is also a good discussion of why this is occurring - but the Americans are still talking about regulation and oversight. They are the best example of why neither is a solution. The proposed hub is intended to address this problem by having interested and committed people from the local community there regularly to see and question.

This video also exposes the dangers of a close link between politicians and the market showing how the industry has been protected. Our politicians also work closely with the providers rather than the community and the same situation exists here.

While the financial links keep politicians quiet, the truth is that politicians in the USA are now trapped because so much of the sector is controlled and operated by these chains that there is no one else to do it.

Pressure on them will only harm the residents and there would be chaos if they collapsed. This almost happened in 1999 when government cracked down on rorting. They had to help rescue the companies from bankruptcy because there was no one else to provide care.

This video is not nice viewing, but I think that anyone who is advocating and supporting the consolidation of our market using the sharemarket and private equity should be made to sit down and watch all of it. It's an in depth analysis and not a short clip. 

The proposed aged care hub attempts to address these issues by creating an intrinsic mechanism that fundamentally changes the pressures and social dynamics in the system.

Consumers organisations in the USA: The National Consumer Voice for Quality Long Tern Care is an organisation established in 1975 to pursue better care for the elderly.  The website describes the concerns in the USA and not surprisingly staffing, something that is systematically avoided by politicians in Australia, is one of their major concerns.

What has always interested me about the USA is that with all of the data they have, they carefully avoid criticisms of the marketplace or the impact of competitive pressures there.

I am sure that some of the leaders of these groups are aware of it.  The problem for them is that any criticism of the market in the USA is tantamount to heresy and would be attacked by the right. They would lose credibility in their own organisation. The competitive marketplace is considered to be the American Way.  To criticise, is an attack on the idea of being American and would undermine the organisations credibility, their membership and their ability to act effectively.  Compare the extract below with  UK community organisation's concerns about privatisation in previous sliders.

Nursing home resident experiences and more than 100 studies, articles and government documents have identified the important relationship between staffing and quality of care. Even the best nurses and nurse aides can’t deliver quality care if there aren’t enough of them.

The Federal government has found that nursing homes that do not meet a recommended level of 4.1 hours per day of total nursing time per resident may be putting their residents at risk. This is an issue that affects all of us; more than 40% of Americans who reach the age of 65 will spend some time in a nursing home during their remaining years.

Source: Better Staffing: The Key to Better Care  The National Consumer Voice for Quality Long Tern Care website

Wouldn't it be wonderful to know just how many hours of nursing care residents in Australia are getting?  4.1 hours is what experienced experts in the USA consider a safe level. When they get less than 4.1 hrs then problems become more likely.

The legal solution: Citizens in the USA simply do not have a credible solution to the aged care problem that the market has created. Anything other than a free market is un-American. They don’t see it as a system problem as much as a failure of the individuals.

The only solution they have is retribution and deterrence. They look to lawyers, the courts and massive penalties. They have been running law suits and getting massive penalties for at least 20 years. In most states politicians have blunted the deterance by capping the maximum damages that can be awarded. There has been some impact, but the costs of the lawsuits have pushed up the cost of insurance (which pays the settlements) and this has increased the costs for nursing homes putting more pressure on the system. Its a vicious circle.

I don’t have any difficulty in taking legal action when there have been failures - but on its own, it does not work effectively. It needs to be accompanied by a change in the system itself, one that turns off the pressures that drive the market to neglect the elderly.  The proposed aged care hub is intended to do this.

The YouTube video link below, is an advertisement for a law firm but it states the problem and illustrates the solutions offered.

The providers response: To counter this, nursing homes have been forcing seniors to agree to arbitration in their nursing home contracts. Residents then have to arbitrate with a company friendly lawyer instead of, or before, they can take legal action. This is legal but the arbitration process deprives them of many of their rights and disadvantages them.

Another consumers group Caring Across Generations is trying to rally the community to press for change to the US system. One of the things they are doing is pressing to have this issue addressed.

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We would love to hear your thoughts on the direction aged care should take in order to make life worth living and working in Australian nursing homes: Join our conversation  Author: Dr. Michael Wynne, Copyright 2015