In Parts 1 and 2 of Solving Aged Care, I have strongly supported a proposal by Professor Ian Maddocks, Senior Australian of the year for 2013, for the creation of a Community Aged Care Hub in each local region to oversee and manage aged care. I have added several additional items to his proposal and described the sort of aged care hub I envisaged.
On this web page I explain the reasons for that proposal in greater depth and show how it will address the problems in aged care. There are many ways of understanding what is happening in aged care and we need to look at those and see if the proposed hub makes sense there. By looking at the reasons, we learn a lot more about what is happening.
Summary of this page
This page looks at aged care from many different points of view to see how the operation of the proposed community aged care hub can be understood and whether there might be problems.
- The page starts by looking at knowledge theory and educational theory to show that the hub conforms with current thinking and evidence. If successfully introduced, it is likely to do what we want it to.
- It makes a diagnosis and looks at the underlying pathology. As it examines the various issues, it looks at how the proposed hub would work there.
- I explain why this web page only contains an outline diagnosis of the problems and why a detailed exploration and analysis has been put on another website. I stress that in spite of my criticisms of the system, even the worst systems can be made to work. Many have provided good care in a bad system – but too many have not.
- The page examines the basis for making a diagnosis of a failed market and then goes on to explain why this market has failed
- It looks at the aged care market as part of a wider problem of failed social systems and names the problem in failed systems culturopathy (cultural pathology). It gives a brief history of culturopathy going back into medieval ages following this through to capitalism and finally to the radical shift in capitalist thinking in the 1970s and 80s. This led to what is variously called economic rationalism or neo-liberalism - the belief system on which the current aged care market is based. It explores some of the impacts of this system on society and on communities as it affects aged care. It is currently under pressure.
- It returns to culturopathy to examine the psychology at work and the social forces that are generated particularly as they apply to aged care. A major problem in aged care is the replacement and subjugation of a long established culture developed within the sector by a new and very different culture that is in conflict with and frequently incompatible with the original culture. The page examines how both individuals and organisations rooted in the older culture respond to this.
- The typical pathological features of a culturopathy are considered and their presence in aged care documented. These include that they are underpinned and depend on a cascade of illusions which need to be protected. They are protected by controlling information (censorship), by neutralising critics, and by keeping important appointments to regulatory bodies and inquiries within the family of true believers so that no one rocks the boat. The lack of solid information on which to base opinions leads to widely different understandings and very different views about what is happening in the system.
Fragmentation: Partly as a consequence of these protective responses, the oversight and protective mechanisms that might expose problems and make this system work are fragmented and ineffective. Failures are not adequately recorded, documented or acted on. The proposed hub addresses this issue by controlling, augmenting and coordinating these mechanisms.
New initiatives: As a result of the criticisms and community anger, a number of new and once again fragmented initiatives have commenced or are planned. While there is merit to some of the ideas, they are being implemented within 20th century control and manage philosophy and do not conform to the 21st century community partnership model. There are many potential problems. The proposed community aged care hub would integrate these new developments within a community service and overcome the majority of the problems.
The essence of the proposed hub: The proposed hub creates a broadly based representative community organisation to control aged care locally, one that is in keeping with new 21st century insights into social process. Not only does it address most of the problems in the current system, but it creates a friendly respectful forum within which constructive thinking can flourish, one where new patterns of understanding can develop and be applied – a place where illusions can be confronted and debunked.
As I indicated earlier, my experience with different belief systems led me to become interested in developments in social thought that built on insights by philosophers during the 19th and early 20th century. These are now grandly referred to as the Sociology of Knowledge and much has been written which I have not read – but some quite simple insights can be used to help us understand what is happening around us. We all have a general idea about this because the ideas have been expressed in different ways and many are a part of every day dialogue. But it is worth diverging away from aged care to bring a few key concepts together and then show how they apply.
If you find the first section too complex and difficult to follow, skip to the heading "Problems in making a diagnosis" and the second group of slider sections starting below that. However, the first section will help you to understand what is happening better.
How do we know and understand?
We can start by accepting that the world and our place in it is all part of a vastly complex structure and we only get a rather limited handle on it with our five senses. Scientific endeavour has provided us with tools that have given a greater insight into the physical world and we have used that very successfully to understand more. Although we have progressed in understanding ourselves we have been less able to grasp and apply those ideas to our complex societies.
Simply seeing and hearing is only the beginning. To do anything with what we see and hear we have to understand and as social animals we have to share those understandings with one another. The way we do this is with language and that is what makes us unique. So language is the tool that enables us to understand the world we live in but it also limits our understanding to the things that our particular language enables us to understand.
To understand something better we often have to develop new understandings with new words and then impart those meanings to others. Special interest groups develop their own words and meaning systems to grasp and understand a particular bit of the world. More widely, the general public also changes the way it sees things and the words it uses over time. Different civilisations and different cultures develop different world-views.
So the world we live in is a world full of meanings and understandings - and those meanings and understandings are the product of our talking to one another about the things we see and experience as we lead our lives and make a place for ourselves there.
Although our understanding has its origins in our experiences, it's not actually the real world. It's the world as we understand it. Others who experience it in different situations and use different languages, understand the same things we experience quite differently so we don't all agree.
So the theorists talk about the social construction of reality – the ideas and understandings that small groups, large groups, cultures, nations and even the whole world create and then come to accept as real at any one time – the ideas that give meaning to our lives. Some form the basis for large civilisations. The reality (understanding) that we have can sometimes be very different to that others have.
A variety of names are given to these ideas about the way the world is. We talk about belief, ideology, paradigms, metaphors etc. They all refer to patterns of ideas that we use to understand and to make what we do meaningful. That is what I am going to talk about as it affects aged care.
What do we do with our knowledge?
We poor mortals have two fundamental options in this world, either we live our life or we terminate it. Most of us prefer to live it and if we do that we have no choice but to act and do things. To do that we have to engage with others and build the understandings that we need so that we can do things, become someone and have an identity – an identity that we and others around us accept.
We are all born into a culture so we have a ready selection of understandings to select from and adopt, ones that have worked for others. But often by the time each new generation arrives the world has changed and moved on so we can struggle to find meanings that work for us.
Having a meaningful way of understanding is so important to us that when it is difficult to make sense of something we simply fill in the gaps as best we can and we do that in ways that allow us to live our lives successfully. A world that we cannot understand is a highly confusing and distressing one.
If the world we are in does not offer the understandings and opportunities that we need to build our lives then, as individuals, groups or even nations, we will fill in the gaps as best we can with the best explanations we can find and if we can't find any we make them up. So we get bizarre religious cults, national or global ideologies that are harmful and angry rebel groups that develop reasons to demonize the dominant culture and attack it. The fanciful illusions we create to fill the gaps may be imaginary, but there is nothing imaginary about the consequences. The history of mankind is the story of the consequences. These are sometimes good, but very often they are bad for some.
Defending our beliefs
The ideas that we develop in our lives are so important to us that we frequently apply them to the whole world and to parts of life where they do not make sense. We ignore the obvious contradictions and consequences. But in time, conflicting evidence mounts up and often this takes the form of harmful consequences.
These ideas are the ones that give our lives, even our civilisation meaning. We have used them to build our lives. We may have fought for and sometimes died for them. We protect them and instinctively react to any challenge by shoring up those beliefs. We find ways of hiding, ignoring or explaining away what we dare not acknowledge. We demonize our critics. Instead of addressing their arguments we attack them and try to destroy their credibility – even kill them.
To those who are harmed, those with different views or those looking in from outside, these indignant angry people can be seen as evil or self-serving. They are of course self-serving and desperately so as the whole meaning of their lives is threatened - but most are not evil. They are simply behaving humanly and if we had lived their lives we would probably behave similarly. If we step outside ourselves and look at our lives as an outsider we will find that at some time we have all behaved like this.
We can and do sometimes, respond differently
When we were younger we developed our ideas and constructed the understanding and meanings that we use. Most of us hopefully found this an exciting and an exhilarating experience. At some time later in our lives, many of us do challenge and rethink the ideas we started with and construct a new set of understandings. We usually find this interesting and rewarding.
So why do we sometimes respond defensively hanging on to ideas that don't work, and yet at other times behave so very differently? It is quite complex, but the context that we find ourselves in - the situation and the people we are dealing with - are important.
At one time we will be strenuously defending what we do and believe from criticism. We will be doing so in co-operation with people who think the way we do and who are also defending. At other times, we find ourselves constructing and building new ideas and even new selves. We are frequently in new situations with new people around us.
These ideas have become important in education and in communication theory where the theories and understandings that have developed have, not surprisingly, been called "constructivism" – trying to create an educational context where new knowledge and understanding becomes interesting, exciting and rewarding.
Danger: The problem with being in a constructive phase is that too often in our enthusiasm for new ideas and new ways of thinking, a group with new insights can discard everything that was known before – the good with the bad. They can delude themselves in order to make the world fit into their new grand ideas.
They will dismiss the sensible and describe what does not fit into the new pattern of thinking as "obsolete". They ignore the sensible reservations of those with practical experience and will marginalise them. They feel quite certain that what they propose is going to work better and create a wonderful new world. Instead, we end up with all the problems we chose to ignore plus a few more.
That is what happened in the 1970s and 80s in the UK and USA and in the 1990s in Australia. Starting within a group of economists in Chicago, it caught the imagination of powerful people and became a dominant ideology. In spite of remonstrations, health and aged care became a part of it. By the 1990s information about failures was readily available in health and aged care – there were widespread problems in the USA. All this was drawn to Australian politicians' attention but they, like their counterparts in the USA and the UK, ignored it.
Aged care is only one of the sectors in society that has suffered because of it. Those ideas are now increasingly threatened and that is why government and the aged care sector are being so defensive and so secretive. They are locked into a belief system - a condition lnown as "paradigm paralysis". While politicians claim to be listening to people they only hear what they want to hear – what their beliefs allow them to hear.
When do we defend --- and when do we construct new knowledge?
So the argument I am making is that aged care, like the political belief system that gave rise to it, is coming apart at the seams. The belief system is not popular in the electorate. People are looking for change but don't like what is on offer.
In aged care it was evident to some that there were problems from the very beginning. Those problems have been apparent for at least 15 years. The evidence is growing steadily but all those involved have been in defensive mode. They have attacked their critics, denied that anything was wrong, claimed failures were exceptions and when under pressure, have tried to patch the system. It sometimes helped for a while.
My criticism is that this has been a response to the symptoms without attempting a proper diagnosis. They have treated the symptoms and not the disease, which is not cured. The real problems have not been addressed because making a diagnosis and doing so meant challenging those deeply held beliefs and admitting they were flawed.
Making a diagnosis is usually not difficult - but to have it accepted and acted on requires much more than that. It requires a constructive environment where people can engage with each other in real life situations, identify the issues and come up with ideas for dealing with them.
Knowledge and the Community Aged Care Hub
The proposed Community Aged Care Hub is intended to create a context within which constructive engagement has to occur. It will create an organisational structure in charge of the knowledge being gathered about aged care. It will be close to the coalface where care is being provided, so any discussion will be centred on real life. The providers will be sitting down and talking to a broad range of people with very different ideas.
This will not be a theoretical hour long talkfest in some distant hall, but a practical ongoing, long term, to and fro animated discussion within the whole community, inside the nursing homes, on the streets and in the homes of families - all the places where the aged, their families and the community mix. This would be a discussion centred on real experiences, real knowledge and real happenings in the community bubbling up the system rather than being rammed down from the top.
The best way to stop constructivism from overshooting and going off at another tangent is to tie it as closely to real situations as possible and to base it as broadly as possible across all sectors of the community – so that it will be looked at and argued about from as many different perspectives as possible.
Clearly, that is not going to happen suddenly. It's not going to be efficient and it is going to take time. There are disparities in knowledge and as a consequence in power and credibility. The community has been out of the aged care loop. It has been disengaged for so long that it will have to find it's way again.
So there is a goal, an ideal, but it is a long term ideal to work towards. It's where I am suggesting aged care should be going.
So what is this hub intended to accomplish?
It is not:
- a new system to replace what we have – a new belief system in itself
- a structure intended to address a critical flaw in the market system we have by creating an effective knowledgeable customer – or more accurately a proxy customer close to and working with the consumer – making this market work.
- a forum directed to acquiring accurate data, evaluating it, building a knowledge base on that, and then coming up with sensible understandings, solutions and a path forward. This must be a path based on the needs of the aged and the system that serves them – as contrasted with the needs of a belief system imposed from outside.
- sufficiently broadly based in the community to prevent any attractive but not soundly based ideas from being imposed by another group with an agenda that is not about aged care.
So how do we get from where we are to where we want to be?
Problems in making a diagnosis
Making a diagnosis of societal dysfunction is also very different to other diagnoses because it means treading on a lot of toes. Dysfunctional social systems don't collect the sort of data that will challenge and criticise the belief system that their citizens have devoted their lives to. While not intentional, their own thinking is designed to shield them and obscure – else the culture would not prosper. So to see what is happening we have to use other patterns of thinking and look in from outside. We need to look at what people who are part of that culture are saying and doing, what those who have fallen foul of it are saying, and what critics with a different perspective are saying.
Why have two websites
Because we don't collect information about care, we are limited to the information publicly available to us, much of it from the media. The gut response to challenging criticisms is an angry denial and an attempt to discredit the critic. If any admissions are made, they are forced and grudging. Some of the criticisms may well be inaccurate or even wrong - and that will be siezed on to discredit them all.
What matters is not that individual allegations are made - but their number, their nature and the pattern that emerges – a pattern that fits and makes sense and from which we can draw conclusions.
I have done a detailed examination of what has been happening in aged care scanning through large numbers of publicly available reports and quoting from them to make a diagnosis and explain what is happening. I explained why many will be angry above and outlined the problems in doing this on the web page Speak out if you dare in Part 4.
Some will disagree strongly with what I have said, feel that they are being unjustly accused and be angry. They may well respond aggressively. In addition, most of the detail and the arguments will only be of interest to those needing to look in much greater depth or wanting to challenge my diagnosis. I have no idea how many will want to do that but I would welcome well-founded criticism. Social change always has a negative impact on some and a benefit for others. I can understand that people will be upset, but I do have to back up my diagnosis and arguments.
I want the Aged Care Crisis website to be a constructive one coming up with ideas - and not a responsive one dominated by angry disagreements about whether any particular bit of evidence is correct or not.
It is clear that, in spite of the best intentions, strong motivation and a belief in what they are doing, the aged care system is not doing as well as it should. It needs to change but without too much disruption and as little negative impact as possible. A thorough discussion of the problems and a sensible plan of action should not be derailed by a reluctance to stand on someone's toes.
But a diagnosis is only that and it needs to be confirmed by actual data – accurate local data collected independently and transparently. Its accuracy needs to be discussed and debated. The collection of local data and its evaluation is an essential and non-negotiable role of the proposed hub. Internationhal data is valuable. Because we don't collect it ourselves we have to rely on theirs until we collect our own.
There are many strong pointers to the diagnosis in the information we have. They are difficult to explain any other way, but we don't have any confirmatory hard data in Australia so I don't want to get too bogged down in that on this website.
I have therefore made the following compromises:
- On this page and within the Solving Aged Care section of this website, I give only an outline of my assessment, my reasons for that and concentrate on how the proposed hub would address each of the issues identified.
- My own website Inside Aged Care is likely to have a more limited readership. On that web site I explore these matters in depth in multiple pages using examples to make the points and expose the patterns of social dysfunction that I have identified. Those interested in exploring in that depth or in disputing the assessments I have made, will want to read those pages. Lets debate the issues and the conclusions there.
Note: there is a link to them at the foot of this web page.
The human spirit can triumph but not always
I am very critical of the aged care system, but while I criticise what people say, it is a criticism of the system and the cultures that sometimes develop there - not of the individuals or their genuine intentions.
Human beings are remarkable in their ability to do the most marvellous things in the face of adversity. It is not that people are not trying and that there is not good dedicated care. Because we don't collect information we simply don't know how much.
I understand that some will feel that I am criticising them and something they have worked so hard to make work. This is far from the truth. But I think anyone who really looks, realises that the system is not nearly as good as it should be and not everyone is making it work.
The point I want to make is that good care is being given but it is in spite of the system and not because of it. There is enough information to suggest that it is failing far too often – not everyone is able to rise above the system.
We could do so much better if we had a system that was really about care all the time and not about something else. We would be far better with a system where everyone is driving in the same direction.
Is aged care a failed market?
On the introductory pages of Solving Aged Care, I presented an opinion that the aged care system was broken. I then asserted that it was broken because it was a failed market. It had failed because the majority of users of this market were ineffective as customers. I need to establish reasonable evidence to support that before examining the pathology (the processes at work) and refining that diagnosis further.
Why aged care is a failed market: Evidence
Ancient knowledge ignored: For over 200 years it has been a part of our knowledge base that an informed, effective and powerful customer was an essential component for a successful market. Special precautions were taken in those sectors where customers were vulnerable – a key one being that only citizens known to be trustworthy and who would not exploit customers' vulnerability were privileged to work there.
Market failure: It should not come as a surprise that in almost every sector where citizens lack the knowledge, or the power to be effective customers, the free unregulated market has failed. Instead of working in their best interests, the market has exploited people and often harmed them. This has happened across the world and there have been multiple recent examples in Australia.
The USA: Health and aged care are closely aligned. In the USA both have been in crisis. While efficiency is the great claim for markets, the US health care market is by far the most costly in the world. It has been plagued by frauds and scandals where citizens were harmed. UN figures show that the USA has among the poorest health outcomes in the developed world. Its aged care system has been chaotic with never ending allegations of understaffing and poor care in order to fuel profits.
During the 1990's corporate chains devoted most of their resources to providing profitable step down rehabilitation to healthy people while largely neglecting the frail aged for whom the facilities were intended - but who were not really profitable. While it claimed "economic efficiency" as its reason for entering health and aged care, the US Health and Aged Care markets must be the most inefficient in the world.
The UK: There is a great deal of unhappiness in the UK about the privatisation of services under their National Health System (NHS). Many feel that the adverse consequences have outweighed any benefit. Aged care has been an even bigger problem there. Private Equity groups have been particularly active, leaving a chain of bankruptcies and poor care in their wake.
Health care in Australia: In Australia, an invasion by the large US multinationals with a history of fraud and exploting citizens was repelled at the end of the 1990s by using state probity regulations. The medical profession took on the government in 1998 when attempts were made to introduce the US system. This would have rendered them powerless when confronted by corporate might. They won that battle but are still fighting the war.
In 2002, doctors used their knowledge and the power they had fought for to become a proxy customer. When Australia's largest hospital owner stepped out of line and behaved unethically, doctors took their patients elsewhere and put that company out of business - so stamping their control over the way care was provided in this marketplace. Managers now had to talk to doctors in their hospitals before introducing new policies. We were largely spared and did not follow the USA. In this instance, it helped that altruism and good care were in line with doctor's own professional interests. They had seen what had happened to the practice of medicine in the USA and did not want to go there.
The proposed community aged care hub needs the knowledge and the power to act in the same way if and when this becomes necessary.
Aged Care in Australia: Aged care was turned into a free unregulated market in 1997. Like the USA and the UK, government had adopted a policy of restructuring almost every sector as an aggressively competitive market. Doctors do not have the power and are not in a position to act as a proxy customer in aged care.
This aged care market has been comparatively low-key as the Rudd and Gillard governments were more restrained than the coalition. It has been reinvigorated by the Abbott government's focus on supporting and funding markets by injecting additional funds. It has become a pressure cooker as groups compete to dominate the sector. Good care and market success are linked inversely in this marketplace.
As a general rule, the more profitable and successful they are - then the worse the care is likely to be. It is clear that aged care is at high risk of market failure and we need to look critically at what is happening there.
Rare exceptions or red flags? Like the USA and the UK, there have been a steady stream of press reports over the last 15 years exposing failures in care. There have been ongoing complaints from the families of residents. Nurses too, have tried to speak out or written anonymous letters. Unlike the USA and the UK, Australia does not collect data about failures of care. The actual extent of any problems cannot be determined.
Politicians and the industry have claimed that failures in care are rare exceptions or on other occasions simply a media beat up. When we examine aged care within the context of what has happened in similar situations in Australia and in similar countries, this must be most unlikely.
It is very much more likely that the exposures made and the stories of poor care are simply red flags to a far wider and deeper problem. It is only the most flagrant and unacceptable examples that are reported in the press.
There are many links on the web pages International Aged Care and Further Reading in Part 4. Look at them and see what you think. Are those isolated events? Or do they look more like a wider culture that is not really about care – perhaps something more pervasive?
A section 19 years of care on the web site Inside Aged Care descibes what has happened in aged care in Australia and documents what has happened with multiple examples. Anyone who doubts that this is a failed market and that people are being harmed should read that section.
A high-pressure game
On my own website I explore this aged care marketplace in depth using the metaphor of a high pressures game with a large number of highly competitive players. These include private companies, market listed companies, private equity, banks, turnaround specialists, brokers, analysts, consultants, investors and managed funds. They all need money so that they can get bigger and stronger.
Forced to play are the not-for-profits who provide the best care but who are handicapped by having to waste resources to provide that good care - and by not being able to raise money so easily. They struggle to compete and are increasingly gobbled up by aggressive competitors.
The only party that is not a player is the frail elderly resident who is in the treasure chest holding the money needed to play the game, money that is then divvied up among the players. In the excitement of the game its easy to forget that the intention is to care for the resident and that is what the money is for, but by then there is not much left over anyway.
The proposed hub would change the nature of the game. It would introduce a new player, a protector and exterminator with a ray gun. Players who take their eyes off the residents are vaporised. Those who closely attend to the resident are rewarded.
Deciding to play the game: In this exciting market, those who 'play the game' for the excitement, will do so only while it is exciting. If there is not enough money and they can't win they will leave the sector and go and play somewhere else. They will close up shop and take their money to another game, one that is more rewarding. There will be no one left to care for the elderly.
This situation seems to be developing in the UK. Four Seasons, a private equity group owning a very large number of nursing homes is losing money and struggling. If it can extricate itself - and it almost certainly will, then others will follow. Another big private equity group was clever. It reorganised its large portfolio of nursing homes to give a temporary profit, sold up at a big profit itself and left the purchasers to go bankrupt. There was a scramble to find someone to pick up the pieces and look after the residents.
Those who are providing care for humanitarian reasons – who are there because they care – are likely to be in it for the long haul. They will stay there and do the best they can.
If you examine markets and look at what participants are saying, the buzz word is 'opportunity' and not 'stability'. When a market is stable, there are fewer risks but also fewer opportunities. Those wanting to play the game are discouraged. Are those who are looking for opportunities rather than stability really the right people for this sector?
Those most at risk are the residents. They don't have any choice about being part of this game and they have no opportunities there at all. Most of them don't survive very long!
The section The Aged Care Marketplace on the Inside Aged Care web site looks at this market game and then goes on to look at the impact of Private Equity in aged care as well as many other aspects of the way this marketplace has impacted health and aged care.
International data, particularly from the USA, shows an inverse relationship between failures in care and the number and quality of staff. Between 60 and 70% of expenditure in nursing homes is on staff – the biggest cost. The best staffing and care is in not-for-profit facilities. Both deteriorate as the pressures for profit increase with a gradient through private for-profit, corporate market listed for-profit (accountable to shareholders) and private equity who typically buy less profitable businesses cheaply, make them profitable as quickly as possible, and then sell them at a huge profit. The care gets worse the longer the private equity company owns the aged care business.
The pressures for profit and growth increase rapidly along that continuum - so does the excitement of the market game for the various competitors. The most competitive succeed. Once again, a perverse Darwinism operates. Those who can successfully take more money from care are more successful and put the others out of the game. It is clear that ownership is a critical factor, if not the major factor impacting on care. Australian government policies are currently driving this process by increasing competition and allowing big companies to take more from care.
In Australia we have not kept a record of staffing numbers or skills and we do not record and collect data about failures in care so we are unable to show that this is happening here too. But some preliminary and indirect data points in the same direction. These are the ACC evaluation of accreditation results in 2008 and the examination of sanctions by UTS academics in 2014. Both suggest that for-profits fail more than twice as often as not-for-profits.
The importance of the customer
Markets are impersonal entities so are neither good nor bad. They are simply a mechanism for transacting business. Values, norms and concern for others come from people. In a high pressure competitive system, the pressure on those providing the service is towards profitability and doing whatever is necessary to increase that. Anyone who compromises on that is no longer a team player and is pushed out. There is consequently little room for empathy, values and humanitarianism. The greater the pressure on the players, the less room for these distractions.
It is the effective customer with market power who can insist that empathy, values and humanitarianism are part of the service. By making these attributes a condition of their support they make providing services in that way more profitable. The pressure on the employees providing care can be removed. They can give expression to their humanity and do what their consciences indicate is required. It has become profitable to do so.
An effective customer is particularly important in those sectors where genuine empathy, trustworthiness and humanitarianism are required. Effective customers unlock the barriers that constrain the employees and release their humanity.
It is worth noting that vulnerable employees are also at risk of being exploited in the marketplace. Migrant workers and international students working part time are particularly vulnerable and have been extensively exploited as was recently revealed in the 7 Eleven scandal. In aged care it is international migrants training to become carers who have been exploited leaving them out of pocket and improperly trained - a hazard to those they care for.
In market theory an effective customer is a necessary condition for success. What we are seeing in aged care is the logical consequence of not having one.
Culturopathy: A name for a pathological process
If we look from many different perspectives we gain greater insight into what is happening. Because this is a process that harms people and/or society I am going to use a medical metaphor. I use terms like diagnosis to give it a name and define it, and pathology to describe the processes at work.
I start by giving a name to the most common pathological process behind failed social systems including failed markets in vulnerable sectors.
A name for social pathology
Groups of humans have embraced vast numbers of strange ideas, sometimes using them to successfully build vast empires, but at other times they have done great harm. In spite of its prevalence, we don't have a word for a culture or pattern of thought that people believe in but which fails or harms society. Ordinary decent people can be persuaded that they are doing good things even when they are deliberately harming people. At other times, they are simply blind to the consequences of what they are doing.
I have coined the term "culturopathy" (meaning a pathological culture) to describe this.
Culturopathic behaviour is almost invariably supported by illusions that make what people feel they are required to do legitimate and desirable. This extends from doing things that unecessarily inconvenience others, to chopping off unbelievers heads or a true believer taking control of an airplane full of people and using it as a missile that kills thousands. It can require profound belief and dedication.
Are the people themselves evil? A recent research article describes the willingness with which nurses in Nazi Germany participated in the killing of children with deformities who were seen as genetically damaged and a threat to the gene pool. They saw protecting the gene pool as a noble service to the Reich and had no qualms. They saw, but they did not comprehend what they were doing because the belief system they had become a part of did not include that capacity.
A more recent example is the justifications found for illegal "rendering" and torturing of unconvicted people suspected of being terrorists by the Central Intelligence Agency. The practice approved of and supported by the US government and sanctioned by the president of the USA. ABC Four Corners explored the issues.
I am not suggesting that aged care is in the same class as these examples, but they make the point and illustrate human behaviour.
A history of culturopathy
We can trace the history of culturopathy with a few examples. In religion in the middle ages, illusionary beliefs led to the burning of witches, the Spanish Inquisition, and a multitude of crusades and religious wars. Our western heritage and our achievements grew from those civilisations and they inform the present. But they often had a culturopathic component or had culturopathic subcultures.
In more recent times we have had secular ideologies. The world in the 20th century has been plagued by fascism and illusions about race that resulted in the holocaust, the killing of children with deformities, world wars and then apartheid. Socialism was relatively benign but communism resulted in enormous hardships and millions of deaths in Russia and China. The emergence of fundamentalist Islam this century has released chaos across the world, many brutally killed and vast numbers of homeless refugees fleeing their persecutors - illustrating once again the power of belief and our vulnerability to grand but alarming illusions.
The most successful and enduring of these ideologies over the years has been capitalism in democratic societies. An explanation for why this worked is that there was a balance between the capitalist market, politics and civil society. Like the customer in a market, civil society decided how and where the market operated and the way it was required to behave. It also controlled politics holding its leaders to account and making sure they did what the community wanted. The broad range of opinion and the power structure constrained ideological excess.
Neo-liberalism/Economic rationalism: A new ideology, with a new set of illusions developed in the late 1970s. It originated in the school of economics in Chicago. In the 1980s Reagan in the USA and Thatcher in the UK adopted it as policy. In the 1990s it came to Australia. Milton Friedman, an academic founder of the movement in Chicago was adviser to both Reagan and Thatcher.
Put simply, it was a belief in free competitive markets which saw them as being a universal good and to be universally applicable and beneficial to all sections of society. Because markets were miraculously thought to have values and be self-correcting, they did not need regulation or onerous oversight. Any form of control was seen to impede the way the market operated and stop it from working its magic. These needed to be eliminated.
The same free market principles were seen as applicable to every sector of society. It was a one size fits all model. An army of managers were trained in business schools. They were employed to reorganise all sectors, including health and aged care, along the same principles, whether suitable or not.
One of the major consequences of this has been the rise and dominance of the market sector at the expense of both civil society and politics. Both have been acculturated and acquired. Both speak and think in market terms. Not only do politicians think like businessmen, but they are responsible to them rather than to civil society. They get their money from the market and depend on it to promote their policies.
By using the media to control the way civil society thinks, both markets and politics have been able to maintain this situation and protect their illusions. As the flaws in the belief system become increasingly more obvious, civil society finds itself powerless and unhappy. Government cannot respond to it because it is now responsible to the market. So there is an impasse. Democratic society is in chaos, unbalanced, ill prepared and unable to respond sensibly to the many crises that it now confronts.
The impact of neoliberalism on aged care: As a culturopathy neo-liberalism is not quite in the same league as the holocaust. It is not yet terminating the elderly who have become a drain on the budget! But there have been many consequences of the neoliberal agenda, some beneficial and others not. The obvious culturopathic component is that many of those sectors without effective customers are harming or exploiting the vulnerability of those they should be serving, and aged care is quite probably one of them.
When is regulation good and when is it bad?
A political culture whose mode of operation is to remove regulation is faced with the increasing need to respond to the failures and its only option is to regulate - eg police checks.
The record of processes like this whether by accreditation in Australia, by the Quality Care Commission in the UK, or by the state and federal oversight system in the USA, is poor. Government regulation to contain the dysfunction that results from strong social forces seldom works well and can be considered bad regulation.
Another response is driven by the emergence of uncomfortable facts and vocal critics. There is increasing pressure to suppress information - so introduce some form of censorship - and to pass legislation that stigmatises or silences critics. That also is bad regulation.
By a regulated market, I am talking about regulations that restructure society and the way it operates so that the social forces are changed and no longer drive people to do the wrong thing. That is good regulation. Oversight regulations would then rest lightly and be seldom needed.
The probity regulations that the Howard government "liberalised" (i.e. abolished) in 1997 were good regulations because they controlled who could operate in this vulnerable market by restricting it to those who could be trusted. These pre 1997 probity regulations clearly indicated the sort of people and the sort of conduct that was required of those serving this vulnerable sector. They gave legitimacy to a desired culture and stigmatised undesirable cultural attributes.
The hub legislation: The legislation needed to set up the proposed community aged care hubs would alter the social forces at play so would be considered good regulation. It would change the social dynamics within the sector. This would enable the community to decide on the sort of people or corporations that they will support and make that clear. The necessary processes for collecting data and monitoring performance are intrinsic to the proposed model and not imposed from outside so are not experienced as arduous and burdensome. Performance in caring will be open and on display so staff can bask in their achievements.
The "Hollowing Out" of society
There are other culturopathic consequences of neo-liberalism, particularly managerialism and its focus on a top down organisational structure. All the skills and control has come to lie in the hands of centralised government and corporate managers. Services across the nation have been sold or given to the market to organise or run.
The consequence is a loss of knowledge, skills, control, interest, confidence - and a loss of power in communities across the country. This has been described as a "hollowing out of communities" - but it is also a hollowing out of civil society. The people who should be holding the government and the market to account no longer have the knowledge, interest, or the confidence to do so.
Civil society grows by being involved in the affairs of society. Involvement brings interest and animated discussion. This leads many to study and research and so build their lives by increasing expertise. Identity includes civil as well as a marketplace identity. Relationships are built and society grows. This sense of society and the web of relationships is called social capital to contrast it with financial capital. It builds society's intellectual and individual "wealth" as contrasted with its economic wealth. Both are needed and this is not a suggestion that we ignore our economic wealth.
The focus on economic growth and management has derailed civic development and this has come at a time when we desperately need civil society to be knowledgeable, informed and active. We need a political system that works because it represents civil society. We need to be able to act logically and effectively. It requires only a little exageration to claim that we have one political party representing the big end of town and the other the unions - both market focused. Perhaps a few of the independent senators can be seen as representing civil society.
We have an unstable house of cards built on illusions. It swings about wildly grabbing at ideas as it tries to explain itself. It finds itself weakened and vulnerable, poised on both economic and social precipices.
The writer John Ralston Saul has pointed to our weakness for grand illusions. He goes on to show how these have rendered us unconscious of the real world we live in. His public Massey lectures are titled "The Unconscious Civilization" and it is our civilisation he is talking about. The implication is that our focus on markets has rendered us unconscious of our own society and what is happening there. If so, then Western Society needs to wake up and pull itself together and soon.
Hollowing out aged care: Aged care is one of the worst affected sectors. Care has been taken over and is controlled by managers who become authority figures. This most intimate and important function of any family and every community, the care of its seniors, has been delegated to managers whose actions are driven by ideas that developed in very different contexts. There has been a loss of knowledge, skill, control, interest, confidence and a loss of power.
To be fair, there does seem to be some realisation of this and the introduction of Consumer Directed Care seeks to empower the consumer getting care. The consumer will have choice - but not the knowledge or power to use it effectively. The managers are not going to relinquish control. The government and the market will still be managing it. The community will remain on the outside. Essentially, it's a good 21st century idea introduced in an incompatible 20th century manner and this threatens its success.
The hub: The proposed hub should be more than a substitute or proxy customer for the whole aged care sector. It will be on the inside, at the centre of and in control of aged care provision in each community.
It is a plan to rebuild the hollowed out aged care community and in doing so play its part in rebuilding civil society by creating a knowledgeable, capable informed and powerful community acting for the aged. It is intended to be part of a broad movement that is emerging, one that is exploring new ways that citizens can exercise their citizenship effectively and so rebuild our society and our democracy.
The psychology of culturopathy
It is incredible and seems impossible that so many well meaning people can form groups that adopt illogical belief systems and then knowingly do horrible things. Other similar groups who see bad things happening do not register that they are harmful and inappropriate. How can this happen?
We all come with a built in array of psychological strategies that will shield us and enable us to survive and do well in whatever situation we find ourselves. So there are not only strong pressures that drive us to do all this, but also a set of ready to hand tools that will help us hide what we need to hide as we do what is required of us in order to survive and prosper in whatever culture we find ourselves.
There is a long list of terms used to describe these strategies. They include selective perception, wilful blindness, compartmentalisation, rationalisation, marginalising critics, and then finally, labelling and an attack on the messenger. The study of group dynamics reveals how groups rally around to support and justify what they do. We can call on all these strategies when we need them.
In vulnerable sectors: Health and aged care are sectors in which a market culture has been imposed on an existing values based humanitarian culture. The two are incompatible in some key areas and that incompatibility is difficult to resolve.
Profit must come from the same money that is intended to provide care – a situation that creates tension and angst. Publicly, providers of care must be seen to be providing humanitarian care. Brochures and websites boast about how well they all do this. But behind this pattern of thinking, providers in a competitive market have to adopt market values and behave very differently – reports to shareholder or statements to the market reveal this. They have to decide where to draw the line and it is impossible to meet the demands of both belief systems so the dominant one wins.
The strategy used to bow to the social imperatives of the dominant culture is usually compartmentalisation. The two belief systems are put into separate compartments and isolated from one another. Because the two patterns of thinking are kept quite separate the participants are behaving honestly. They simply respond from one or other compartment depending on the nature of the public situations. One way when speaking to the public - and another when speaking to shareholders. They do not see the contradictions. Nor do they see themselves as lying or conflicted when they make contradictory statements. They look and are being genuine.
The situation is different for the staff, most of whom come from a community or professional perspective - cultures built on a very different view of the world. They are now forced to work in an environment where market priorities dominate. They are expected to think very differently. How do people respond? They have all of those psychological strategies to call on, but not everyone can manage the mental gymnastics.
Some, usually a sizeable majority, will convert and adopt the new thinking, becoming enthusiastic and successful. They will be promoted. Nothing is as persuasive as success. Other responses include those who:
- find the tension unbearable and go elsewhere,
- know but look the other way and in time convert
- accept the situation but stay on altruistically to do the best they can
- are alienated so lose motivation, become insensitive and offhand, behave angrily or brutally, even abusing the residents, and
- finally there are those who feel so strongly that they speak out. This costs them their careers.
Perverse Social Darwinism: We all come with a different genetic makeup and many of us learn quite early how to use those adaptive psychological strategies successfully. Those of us who end up by using them most readily will be the ones who most rapidly convert to marketplace thinking. We will give management the financial outcomes they are looking for, and they will in turn put us into management positions over those who don't convert.
Those who are least suited to provide care gain status and authority. They are put in charge of those who are best suited. This compounds the pressures in the system with the best leaving, and those who remain becoming alienated and disillusioned. It results in a culture that is not focused on care, is dysfunctional and accident-prone. This is why it is important to look at the sort of culture that is revealed in the available reports of failures in care. Has that happened there?
The Community Aged Care Hub: The aged care hub would reverse this situation because the providers of care would be working with and providing services to a community focused and dominated group of people. With the community at the centre of the process and the effective customer, the community and not the market would set the cultural environment for those who wanted to prosper. The big corporations might still have to tell their shareholders what they want to hear, but to succeed they would have to actually care and be seen to be doing that. The community culture would dominate.
Staff from the hub would be in frequent contact and on good terms with staff and residents. The culture in the facility would be obvious. The appointment of front line managers with an inappropriate attitude to care would become impossible. More suitable staff would be attracted and promoted.
A dilemma for the not-for-profits
The not-for-profits are church, community and government organisations. Most came into existence as community groups formed to care for the sick and the frail, eking out whatever money they could raise to meet their mission of care. They were a part of the community. The community was the reason for their existence and their existence was underpinned by community values and beliefs.
They are now forced to operate like, and compete with, for-profit operators whose reason for entering this market is to make money for shareholders. Not-for-profits have to employ managers trained in marketplace thinking to teach them how to do this. They have to start thinking like a for-profit if they are going to function in this market.
Not surprisingly, when we look at what they are saying and doing we see the same use of compartmentalisation and spread of responses as I described above in regard to staff. There are those who convert and adopt the market claiming that there is no longer any difference between for-profit and not-for-profit. Others decide to opt out and sell up. Then there are those who insist that they are very different and that a sense of mission is vital. Even when they embrace the market they believe that providing good empathic care will make them successful there.
The not-for-profits who do this may sometimes be quite successful and find a captive or niche market, but if we look at what has happened in other countries then we see that good care and a mission is usually a handicap. The ones who maintain their mission successfully are the exceptions rather than the rule. Not-for-profits in the USA have ended by selling up or forming partnerships with for-profits who then operate the facilities. This happened at such a rate during the 1990s and early 2000s that the big corporate purchasers were called PACMEN after the 1980's computer game of that name.
If we look at the market we can see the not-for-profits copying the for-profits and offering the same sort of services in order to make more money. They must to survive. We can expect to see the same sort of failures among not-for-profits that have characterised the corporate and private equity providers. This is apparent in the USA and I think it is starting to happen here too.
The Community Aged Care Hub: The aged care hub is intended to make good care the focus of the market and mission a valuable attribute. In doing so it will make the not-for-profit providers viable and competitive. It will also reconnect them to their roots in the community. The intent is to save them from irrelevance and even extinction – to create an environment in which their ability to provide better care will enable them to prosper and succeed. To compete with them, for-profits will have to follow their lead.
Note: The sectioin Cultural Perspectives on the web site Inside Aged Care explores the nature of culturopathy, illustrates its extent in vulnerable sectors in our society today and then examines the difficulties for the not-for-profit sector. It is illustrated with many examples.
There are some characteristics of culturopathies that allow us to make a tentative diagnosis in the absence of solid data about what is actually happening in aged care.
The patterns of thinking (the paradigms) used will depend on illusions. They will not be logical or valid. This will make them vulnerable and they will need protection. This protection will often take the form of further illusions, often a cascade of illusions to counter the logical inconsistencies that appear. Illusions are maintained by rationalising and by asserting their self-evidentness aggressively and ridiculing critics.
The illusion that free markets were universally applicable and self-correcting led to a cascade of further illusions including:
- Regulations that limit the freedom of markets impede their ability to function and correct themsleves so must be liberalised, i.e. repealed.
- An effective customer is not necessary for markets to operate successfully.
Within this context:
- Competition is a universal good - therefore the more competition the better
- Oversight and accountability restrict innovative and efficient solutions so should be removed or very limited.
- How government and consumer money is spent does not matter, provided the market delivers
- Profit is a reward for efficiency and good service
- A focus on efficiency in achieving outcomes has no impact on the quality of life for those sectors serving vulnerable consumers who needed close and personal interaction – aged care.
In order to liberalise aged care and allow free access to competing providers who would fix the problems in aged care, probity requirements were abolished in 1997. A key consideration in making probity decisions had been the extent to which an unsavoury entity exerted control – the stake that an owner had in the business. To justify this to themselves required more illusions.
- The illusion that owners of the business have no impact on care: It is the "key personnel" (i.e. managers, who are appointed by and accountable to the owners) who make the decisions about care that matter. Note that while the legislation talks about suitable people, "suitable" applies only to the subsidiary managing the nursing homes and concentrates on financial viability. It is possible for a criminal organisation (eg, the Maffia) to buy a company owning and managing nursing homes, as long as the subsidiary company they buy already has approved provider status. They do not have to apply to be approved themsleves. Citigroup, a Wall Street financial giant that has exploited vulnerable people repeatedly did not have to seek approval when it bought Amity care in December 2006. Amity was Australia's largest for-profit nursing home company.
After several failures it was decided that people with a criminal history should not be "key personnel". The "key personnel" that the Maffia appoint to run the facility the way they want must not have criminal backgrounds - yet. Another illusion was required.
- That not having a criminal history would enable managers to ignore what owners wanted them to do to generate profits.
Believers needed to justify abolishing probity requirements, the removal of financial and other accountability, and the abolition of existing state assessment of outcomes and standards of care in nursing homes
- Accreditation, a process intended to assist providers who are motivated to provide care by teaching good processes and certifying that they were in place every 3 years, is adequate for oversight and for ensuring good care is provided in the face of strong pressures on providers to reduce care and game the system.
- That processes prepared for and put on display once every three years are a measure of what happens during the three year period.
- That collecting and publishing actual measures of care is unnecessary.
- Ownership does not matter because the facilities still had to measure up to accreditation standards. This would protect the consumers.
Accurate and properly interpreted data is incompatible with a culturopathy. The survival of all culturopathies depends on their ability to manage and control information. Strategies include simply not collecting information that might challenge belief, suppressing information that does, controlling information, and selectively interpreting the information that is released. These are really all forms of censorship. It is not always done deliberately, but reasons and strategies are developed by finding ways of explaining or justifying it.
Ownership: As owners are not a regulatory concern there is no need to disclose details about owners. It can be very difficult to track down and find who the owners and real managers are and assess their performance. Are they local, or do they dictate policy and manage from the other side of Australia? It is not easy to find details in Australia.
In the USA, hiding ownership is a complex and deliberate strategy. Some US companies operate in Australia. Providers develop strategies to hide ownership in order to protect profits. This is because disgusted juries in the USA award large legal penalties to the angry families who sue. A complex paper trail, if it can be followed, may eventually lead to the subsidiary responsible for care. Too often it is a dollar company and has no money. It promptly declares bankruptcy.
In the proposed aged care hub the communities themselves would be looking at and deciding who was going to provide aged care in their communities. They would insist on full disclosure and then make their own inquiries.
What about Accreditation? During the 1990s there was already a major crisis in the provision of health and aged care in the USA. This was widely known in Australia where several of the giant hospital corporations welcomed by governments fell foul of our probity regulations. This frustrated government plans to use them to "consolidate" the immature health care marketplace.
Accreditation and other forms of oversight had been strongly criticised in the USA because of their failure to detect problems in care. This failure was blamed on commercial and other relationships with corporate providers. The relationships were with the accreditation agencies and the politicians controlling state oversight processes, who were often guests on corporate junkets.
It was also alleged that there were personal relationships and a revolving door between nursing home staff and assessors so that unannounced visits were seldom unannounced. It was easy to prepare for a visit and game the system.
The Australian marketplace and the government were well informed on what had happened in the USA. In 1997 their new jointly planned aged care policy was being heavily criticised. Government were doing badly in the polls. They could not afford to give their critics more ammunition. Accountability and state oversight were abolished. Accreditation became the only form of oversight and the only source of information about standards of care.
Accreditation's failure: Accreditation has been heavily criticised in Australia and some of the allegations about it in the USA have been echoed here. They probably have relevance.
Accreditation is essentially a process directed to helping nursing homes that are motivated to provide good care and keep on improving. It probably does that. But its impact on those who are not well motivated or who are driven by other priorities is debatable.
The agency does not collect data on complications and failures in care so it does not actually measure standards of care. Because of this its utility is unproven, and claims that it does so are based on responses from staff – most of who may be in facilities that genuinely seek to improve.
The paradigms that underpin its operation are directed to supporting industry and as a consequence its performance in overseeing standards, as a regulator and as a source of information for the public are, I believe seriously impaired. It admitted to the 2010 Productivity Commission's Inquiry 'Caring for Older Australians', that it is conflicted and asked to be relieved of some of these functions.
Who does accreditation serve? The close relationships and support of the industry and of government policy is revealed in the way the agency has reported the results of accreditation.
- The agency does not report the total number of facilities failing accreditation as a yearly figure. Instead, it uses a strategy that allows it to report only a small number of those, thereby masking the actual number of failures.
- The agency analyses its figures without examining obvious variables. The quality agency and its predecessor have over the years, reported that for-profit and not-for-profit providers perform equally well at accreditation. However, when its other findings are examined it is clear that for the crude figures to show equal performance then, if properly controlled and apples were compared with apples, the figures would show that not-for-profits were performing several times better than for-profits. When Aged Care Crisis analysed a sample of the figures in 2008 this is what they found. But the agency continued to report its figures in the same flawed way.
At the end of 2014, a study by academics at the University of Technology showed that for-profit facilities were sanctioned for poor care more than twice as often as not-for-profit so showing the same trend.
In spite of the wide publicity this received, the new Quality Agency, presenting at a national conference in 2015, maintained the same flawed claims. When asked to justify this, they supplied the crude figures. When their error was pointed out to them and they were asked to take obvious variables into account and retract their claim, they did not respond.
Both major political parties have supported the market in senility and frailty. Both have encouraged and supported marketplace consolidation and strong commercial competition. Both have been very welcoming to large corporations buying nursing homes. Aged care is a political hot potato and Labor did not want to go there.
The information that is being obscured directly challenges government policies. It supports the argument that they are looking to the least suitable providers and a flawed system to solve the problem created by the current aged care bulge. It suggests that they are deliberately sacrificing the wellbeing of older citizens in order to meet their ideological economic objectives.
But I think that assessment is probably too harsh. It is more likely that the economic objectives have become so central to their activities that they are unable to see the problems in what they do. They simply dare not look and acknowledge.
Why does accreditation fail? The lack of utility of the accreditation results for researchers and for the community, particularly those seeking to avoid poor services or looking for the best, is well illustrated by two examples.
- Firstly, because almost all facilities pass accreditation with full marks, there is no way of separating the excellent facilities from the mediocre. Because it does not measure and report actual failures, no one knows which homes have poor outcomes. It is a good marketing tool for providers, but it does not help consumers. There is little incentive for anyone to do more than pass or game the accreditation standards so it encourages across the board, mediocrity.
- When there are failures, there is an incentive for the facility to correct the failed processes quickly and get reassessed because the first two pages of the failed report are then replaced with a full marks table and result. Incredibly the the old table is removed so that the extent of the failure is obscured. There are no prominent dates to show what has happened. Unless the reader knows what is being done, notices and reads the "Actions following Decision" added paragraph carefully they may not understand that the failures are being obscured. If they just look at the new table they may think that a perfect score has been attained as the previous table has been removed. Unless they actually read through the whole report they may not notice this and even then they will need to add up the number of failures. The failure to have a chart available that sets out the track record of failures of each facility and each company is incomprehensible. Consumers don't want or need to wade through long complex documents to see the records of performance of the companies and nursing homes they are interested in. This does not help or serve the public or the confused seniors and their families who need this information.
Doing a good job: It is difficult not to conclude that the accreditation process was set up to support and shield both providers and government from unpalatable facts and to promote the industry's credibility and image. If so, then it has done its job well. But that is not what the public have been led to believe accreditation was intended to do.
The Aged Care Complaints system: The complaints system was kept under tight government control, initially in the health department and more recently in the Department of Social Services. It has been a source of extensive unhappiness and has been itself the subject of many complaints from the community. A review in 2009 was highly critical of its performance and recommended that it be transferred to an independent authority. This was not done.
The recommendation that complaints were best resolved locally was seized on. The review virtually destroyed the utility of the whole complaints system by embracing our recommendation to place more focus on local resolution - but critically ignored the essential linked recommendation that the complainant should be supported and advised by a trained local facilitator with investigative powers.
Complainants were encouraged to negotiate with the nursing home they were complaining about. Here there was a large power imbalance and many felt that they were talked down to. Many families fear that their loved one will be victimised if they complain and some may have been. The number of complaints has fallen and government has accepted this as a measure of success. It has started referring more complaints made to the department back to the nursing homes.
A situation where there is a gross imbalance in power and where victimisation is possible has been an effective barrier to lodging a complaint and obtaining resolution. The disaffected become even more disillusioned.
With mounting criticism the government has recently moved the complaints system out of the department and put the Aged Care Commissioner in charge of it promising to provide enough funding for this. The Aged Care Commissioner is independent but is appointed by government. The process can still be kept in the family.
It is difficult not to see the complaints system as a strategy to control criticism, but again that is harsh. It is the way culturopathies sensing a problem behave and they are able to find ways of justifying - and then they don't look or hear.
UPDATE: From 1 January 2016, the Aged Care Commissioner will have responsibility for handling aged care complaints - the fifth iteration of the complaints scheme. Changes were announced in the 2015 Budget.
The aim of shifting complaints management across to the Aged Care Commissioner from 2016 is that it should be independent from the department's control, thereby minimising any departmental conflicts of interest, as is currently the case. Whether the new regime will have the teeth and resources to tackle complaints is still to be seen.
The proposed community aged care hub: While the Aged Care Quality Agency would continue to assist providers in setting processes in place, their successful utilisation would be monitored by the hub liaising with the agency.
The hub would also be involved in collecting information about failures in care, standards of care and quality of life. It would be there as a source of information and of support for residents and family. It would initiate and be involved in handling and resolving complaints and be there for both staff and consumers to be sure they were not victimised when they disclosed problems.
While the existing bodies would continue these services, they would do them in cooperation with and through the hub. The community would be in control and know exactly what was happening. It would be in a position to pressure providers and government in order to get what was needed done.
Keeping it in the family
If you don't want to rock the boat, want to get the advice you want, and don't want a prominent person asking uncomfortable questions, then you appoint like minded people to committees and administrative positions.
While there have been a few exceptions, the majority of those appointed to aged care positions and inquiries have had associations with the aged care industry or have been market focused or orientated. Civil society has not been nearly as well represented. This is a service to the public and you might expect them to be.
Example: The Quality Agency is the only body that overseas anything resembling standards of actual care provided. The public depends on it for information that would warn them of poor care before selecting a facility. The appointment of the CEO of LASA, the industry body representing for-profit and many not-for-profit nursing homes to head the Quality Agency is a case in point. Whose side will he be on?
Once again, we can see this in several ways:
- Some argue that an elected government has a mandate. It should appoint those who will do what it wants to administrative positions and to committees that oversee aged care activities. It gets things done. While there is some merit, this is not how others see it - particularly in the current political context. Current thinking is moving towards a more participatory approach in which true believers have to justify their decisions to disbelievers. For example, when voting, voters elect someone to represent them and not an ideology. Appointments to administrative positions represent society and not political parties. This insures government gets independent advice.
- True believers see those who agree with them as sensible, credible and likely to be effective. They have a low regard for those who don't agree with them. They are suspicious of and don't trust those who see things differently. This influences who they appoint. So it's not only about control.
- Another reason is that, as the community has been sidelined, it has lost the knowledge, the confidence and the capacity to undertake these roles. There is no one there to do it. This is a vicious circle because it is self-perpetuating, as without participation civil society is hollowed. By participating it fills out again.
- Finally, there are the cynics who see the process as being kept within the family to protect the system. They don't care how it got like this but they realise that it inhibits change and perpetuates practices that are not working.
The Community Aged Care Hub is intended to reverse this process. As the source and repository of knowledge it will gain influence, status and confidence and so be well qualified to discuss issues broadly within communities and then to take an active part in administering and organising the aged care sector. It will insist on being at the table and will need to be.
Those with information or logical criticisms pose a threat and must be silenced. This takes the form of attacks to discredit the critics, punitive strategies, threats of defamation and actual defamation actions when the opportunities present.
- Academics who have done research and then criticised aged care have been attacked and complaints lodged with their universities. Some claim they have been victimised and the industry has refused to give them the access they need to pursue further research.
- Nurse whistleblowers have suffered all of the fates meted out to whistleblowers elsewhere, although none have gone to jail yet.
- Family members who have spoken out about the care their relatives have received have looked around them and then become vocal advocates. Several have received lawyer's letters. It is not known how many have been frightened by this and have bowed to pressure. The laws of libel in Australia are so complex and so unclear, that others who would like to speak out are too frightened to do so. The legal profession itself is often confused.
- Family members who are persistent about failures in care can be locked out of nursing homes and permission to see their relative refused. The guardianship process is sometimes used to do this.
The community aged care hub: The proposed hub would be working with researchers facilitating their work. They would be in the nursing homes and visiting those receiving care at home. They would be talking to nurses, residents and family so would have a good grasp of what was happening. These are all issues they would be addressing and these things would be largely prevented.
Widely contrasting views
Without accurate information on which to base conclusions, you find that different people have widely differing views about what is happening and about the performance of the aged care system. Usually the further those responsible are away from the coalface, the more rosy their perceptions and inappropriate their ideas.
Staff who have converted to market thinking and practices are unlikely to see failures or complain. They are the most likely to get angry and reject criticism. Relatives of residents who have had bad experiences and older staff who trained and worked at a different time - and return after a long break are most likely to see failures in the system and be unhappy. New staff are more likely to become part of an established culture and not know any better.
There are a large number of contrasting perceptions.
Successful vs failed: There are those who see aged care as a highly successful endeavour to which they have contributed. Others point to failures in other systems and see the same problems in aged care. Staff who have reservations are more sensitive to what is happening and are far more likely to be critical. Families, who have adverse outcomes look around them, see what others don't see and because they see their own experiences being repeated try to do something about it. They may be anxious or upset - and therefore easily discredited.
Starkly contrasting: In aged care we see reports suggesting wide unresolved discrepancies between critics and supporters of the aged care system.
- There are those who think we need more trained nurses in aged care and those who think we can make do with less.
- Others insist aged care is underfunded and want more, while those who look at corporate profits and analysts reports think that there is enough money and that giving more will go to profits and not care.
- Unhappy families who have had bad experiences see it very differently to nursing home staff.
- Staff often see the care provided as falling far short of that management believes it is providing.
- Within the various professions serving the aged, those who have converted to market thinking can see what is considered to be appropriate conduct very differently to those who maintain traditional professional standards.
- In the not-for-profit sector there are widely differing views between those who have converted and see aged care as a business and those who still see it as a mission.
Consumer Directed Care: There are different approaches to CDC including:
- those who see Consumer Directed Care as empowering consumers and letting them choose the care they want,
- those who see it as an opportunity to continue the policy of turning aged care into a competitive market,
- those neoliberals who see an opportunity to shift more of the cost from government to consumer,
- those who see it primarily as an opportunity to increase profits, and
- those who see it as exposing the vulnerable and ill informed to predators in the marketplace.
Innovation: There are those who see innovation as a strategy to market their services and make more money and those who see it as something that people in the community come up with to improve the care and quality of life of consumers and their families.
Funding: There are those who see aged care funding as:
- a fair and well-structured system,
- a source of commercial opportunities,
- a complex and inaccessible system easily exploited and full of pitfalls for the unwary, and
- feel that it is very unfair because the need for future expensive aged care is quite unpredictable. In any truly caring society it would be funded by some sort of long term insurance scheme or by death duties so that the risks are shared.
Incentives: There are those who:
- see the deliberate use of financial incentives as a positive force for the improvement of their businesses and so the service given.
- point to the harm they have done when misdirected because they usually reward profitability and not care. They have been so dysfunctional that in many situations they are illegal.
- see care as essentially driven by empathy and a humanitarian focus – the incentives are internal and social. Financial incentives rewarding individuals for specific outcomes undermine the motivation that depends on their humanity. They distort the service in unpredictable ways. It is preferable to honour and reward people for their achievements than to entice them with financial carrots.
Aged Care Inquiries: Those that think that government inquiries reach conclusions and make recommendations based on the arguments in submissions and those who believe that the inquiries see industry as more credible and knowledgeable, so make the decisions and the recommendations they want.
The Community Aged Care Hub: One of the key functions of the proposed hub will be to collect data, engage with all parties and resolve all these issues in the interests of the consumer and the community. That is how functioning markets should resolve differences.
The parts of the system that seek to protect the community have been fragmented in order to meet political and organisational priorities. These include the accreditation system, the complaints system and the government run advocacy system which all operate separately.
There seems to be little effective collaboration between these services - and separating them in this way reduces their effectiveness. Each agency or group is organised as a hierarchical structure. They become separate 'silos' or entities. The community is engaged by invitation and only on the terms of engagement already decided at the top. More recent research indicates that this is not likely to be effective.
The absence of reliable data means that none of these activities are able to assess their performance. Practices and policy are based on belief rather than evidence.
The Community Aged Care Hub would be an independent community run and organised structure that would oversee, organise and integrate all of the services directed to monitoring and maintaining the standards of services as well as those advising and supporting residents, prospective residents and their families.
These would include data collection, oversight, measurements of standards, accreditation monitoring and community feedback. Support of seniors in the community, advice for potential consumers, and community advocacy would be provided under the control of and through the local community. Each activity would leverage off the knowledge, the experience and the data collected by the others. The system would tap into the wealth of experience and intellectual potential of the entire Australian community. Existing agencies would provide their services by supporting and working through these local organisations.
Each community hub would be there for consumers, supporting them and ensuring that they are able to exert their rights and responsibilities to the limits of their capacity. Advocacy would be a major and important part of the process. But they would also be there for providers and for government supporting them in their provision of services to the community. Those receiving services would be integral to this hub and would exert their citizenship by working with and contributing to the hub.
Making current initiatives work
There are four new initiatives by this government. Two have merit but there are some hazards in the way they are being introduced. There is a fifth initiative that is not initiated through government. It has potential but there are also hazards.
Except for the first two, which are a response to industry, all of the initiatives are a response to the unhappiness in the community and the criticisms that have been made. In all of them the issue of control and keeping it in the family arise. The proposed hub could resolve many of the problems.
Government Initiative 1: The South Australian Innovation Hub trial
The first is a trial that reduces the frequency of accreditation and ACFI reviews, and passes the assessment and handling of complaints back to the facilities being complained of.
The changes include:
- Reduction of audits: Less frequent audits (eg, site audits reduced from once every three years to five years);
- Self-regulation of complaints: Complaints by residents or family member to the Aged Care Complaints Scheme will be referred back to the home in question for resolution, including those that identify serious risk to resident health and safety
- Reduction of ACFI reviews: reduced Aged Care Funding Instrument reviews by the department
While accreditation needs to be restructured, it's the only remotely objective assessment we have, so reducing it without a replacement is unwise. Handing more control to the industry is an ideological response giving the industry total control. It is retrogressive and should be binned.
The hub would restructure this as it would exert far greater control over the services provided and would be the vehicle through which accreditation would be assessed and complaints handled.
Government Initiative 2: Privatising Accreditation
In keeping with its policy of contracting everything and using market forces as the driving force, government has announced plans to contract accreditation to private contractors who will compete for the custom of providers.
A cynic might wonder if a superficial or lenient provider of accreditation will have a competitive advantage. Some may feel that it does not matter, as anything would be an improvement!
New Zealand did this and there were problems. Local councils had so little confidence in the accreditations and oversight that they did it themselves as well so duplicating the process.
If their activity was restricted to education and the other functions were taken over by the hub, it would not matter too much as the incentives would work in the right direction.
Government Initiative 3: Consumer Directed Care (CDC)
CDC is a move towards the 21st century but without leaving the 20th behind. It aims to reform care by placing the funding with the consumers themselves so empowering them to choose what they want from the many choices that providers are being encouraged to provide. It has been introduced into home care and it is planned to do the same in nursing homes. This is a step in the right direction - but its implementation is flawed and there are major risks.
There are some less obvious subtexts. These include:
- Moving far more of the costs from taxpayer to the consumers themselves and rationing the amount of care subsidised by government by restricting the number of high care home care packages. Many wanting to age at home are already finding that they cannot meet the increased costs. They are faced with either doing without or entering a nursing home.
- Pursuing the government's neo-liberal agenda of turning aged care further into a free market system.
- Maintaining control over the system and managing it. The community have been largely excluded from a process that has been developed in consultation with the industry and then marketed to them. Those assessing the need for services and those giving support are being contracted to do so by the government using a competitive commercial process. They are not directly responsible to the local community.
There are two elephants in the room:
- They have been warned about the first but chose to ignore it. It is the vulnerability of the consumer and their families because of their lack of knowledge and power. They are seldom effective customers. There are other sectors where vulnerable people have been exploited after government has contracted the care of vulnerable people to the market. Sooner or later the market has exploited the opportunities presented by the vulnerability of those they were there to serve. Is this going to happen in CDC?
- The other elephant is the refusal to fully engage the community in the design of CDC and to hand control to them. The focus has been on providers and consumers. The community has been largely excluded. Consultation has been tokenistic. This is a community service. To succeed and to be effective it needs to be embraced by the elderly, the families and the whole of the community. Much of it will happen in their homes.
As many studies have shown, the key to success is involving communities in design so that they engage in the process. It requires the courage and the faith to hand control to these communities empowering them to set priorities and drive the process.
The approach adopted for introducing CDC is the same as that adopted by the government in its new aboriginal "Empowered Communities" proposal. As one critic of that process put it "This is in line with the new paternalism approach where governments and policy makers empower themselves to nudge, sanction and discipline Indigenous agency to make the 'right choice' towards economic development". In other words, you can do what you like, provided it is what we want you to do.
The Community Aged Care Hub: The proposed aged care hub is well placed in the community and would have contacts and activities occurring across the community. They would be in an excellent position to know what was happening not only in the nursing homes but also in the community. Concerned neighbours would approach the hub to ask what to do when they saw neighbours in trouble or being exploited.
The hub would exert the same coordination and control over the delivery of CDC as it would over nursing homes. They would assess the services provided, approve providers, collect data and monitor accreditation processes. The various monitoring, assessment and advocacy services would similarly be provided through and coordinated by the hub. They would be well placed to to this as they will be on top of what was happening in their communities.
The service would be controlled and organised by the community and be supported by government. The recipients of care would be members of this community and would be empowered and informed to make the choices they need or want without being exploited.
Government Initiative 4: Quality Indicators (QIs)
Quality Indicators is another good idea but its planned implementation is flawed. The intention is to select up to 5 key objective measures of care like pressure sores that are markers of poor care and measure these. Performance is then rated by awarding stars. Potential consumers use these when making decisions. Objective measurements are what all of the systems critics have been asking for – for years. Government has given in and this is their answer.
There are some potential pitfalls and most of these relate to the pressures generated in the marketplace. These include:
- The stars do help to pick out poor providers but do not give a complete picture of the service provided and more would be desirable. They may not measure what the potential consumer is looking for or needs.
- Funds, staff time and other resources may be diverted from other areas in order to ensure that Quality Indicators are met. While the indicators may be met, other services might be compromised and overall care might not be improved.
- The government will report the results so it will all be 'in the family'.
- The cases will be assessed, and QI's documented and collected by the nursing homes themselves. There is little or no external monitoring. A university study in the early stages of assessing the potential of QI's for improving care was positive but warned that strong pressures might well cause some to fudge the results. The use of QI's in marketing and to inform prospective residents generates strong pressure.
The USA has been using QIs for some years. Providers advertise their success in attaining QI stars. It was recently discovered that some of the best performers when measured using QI's were actually among the worst. They had fudged the reports in order to compete successfully. In a competitive market system dependent on advertising, fudging issues and making impressive claims is normal and accepted practice. It's a small step to doing the same with QIs.
The Community Aged Care Hub: The most important role of the hub would be the assessment of each service provided and the collection of information. It would be working directly with the provider's staff in doing this. Not only would it be very difficult to fudge the results, but it would also be easier to examine a wider range of indicators. Any diversion of effort away from other services would be readily apparent. As the body in charge of aged care services locally, the hub would be closely involved in the QI system so could ensure it worked.
Initiative 5: Consumer web based feedback
This has been a recent response to the lack of information in aged care – an interesting and commendable one. A multitude of independent businesses that invite consumers, their families and their friends to assess performance have emerged. The assessments are provided to the provider so that they can both address the problems in their facilities and also respond to the criticisms on the websites. This is intended to serve consumers by giving them information and providers by giving them feedback so they can address problems.
To respond, providers often have to pay a fee to register with the website to make it economically viable. To be viable and to compete with others providing the same web based services, these web services often rely on the providers themselves to recruit people to complete the surveys. They get their money from the providers and usually offer them the opportunity to advertise on their websites – sometimes charging more for this.
The biggest concern is the dependence on providers for recruitment and for financial support - and this creates potential conflicts of interest. The major concerns are:
- Generating enough responses for each facility for the results to be meaningful and to counter gaming the system. Many older citizens will not be aware of the importance of this and be persuaded by two or three glowing reports - perhaps generated by friends of the provider. The large number of new "feedback" style websites fragments the sector and makes it difficult to get enough feedback to give meaningful information.
- The potential for providers to select whom they ask to give feedback, or to deliberately generate good feedback in order to neutralise any poor feedback provided. There are many ways of gaming the system. Web based feedback has been very popular in the NHS in the UK where a large number of people give feedback. An investigation by the BBC found that large numbers of the responses came from computers in the hospitals themselves forcing at least one of the sites to close as it was unreliable.
- The financial leverage held by providers and the possibility that they will use this to pressure the websites to censor or modify unflattering feedback.
- Feedback is a measure of perception and satisfaction and not a measure of standards of care. Visitors, family and initially residents will be most influenced by the way in which staff deal with them and with the impressiveness of the buildings and accommodation. That is all very important, particularly in aged care.
The crunch may come when they really need care. Staffing is the biggest cost of care and deficiencies here may not be readily apparent. Prospective residents may not know that they need to look further than these websites to see what is happening.
If we look at the playing field, there is a commercial restaurant-like 'owl rating system' being offered by COTA and the NRMA. This is an independent professional survey conducted when requested by a provider and a large number of questions are asked so it is by far the most comprehensive. The provider selects the group to be interviewed. This service focuses on the providers who are the paying clients and can advertise on the site, paying extra for more. Those who fail to get an owl rating are not published. Providers have to improve before resubmitting. The site only provides information on the best providers obtained from a group of respondents selected by the provider. It is of little value for those checking up on local facilities unless they have paid up and have performed well. Those of us who are critical of NACA and COTA worry that this is an attempt by the providers, NACA and COTA to keep it 'in the family' and use NMRA's credibility as a means of dominating this market.
The other websites collect much less information but invite more comments. They include an entity funded by investors, two independently operated by individuals and an Australian version of Patient Opinion, a UK not-for-profit community service. Without any personal experience, I feel most comfortable with the UK offshoot "Care Opinion" and with "Aged Care Report Card" as they seem to be the most independent in funding and in sourcing assessments, and so least dependent on the providers. Aged Care Report Card is independently funded and works with community organisations to bring assessors to their website.
The Community Aged Care Hub: The proposed hub would be well placed to be the agency recruiting and referring people to give confidential feedback. This would ensure sufficient numbers and prevent it from being gamed. They might be in a position to record the demography of those responding, keeping details confidential. This would be valuable additional information. They would be advising prospective consumers so could help them avoid pitfalls such as the presence of only one or two reviewers and would supplement the opnion of users by supplying data about standards and performance.
Fragmentation of the sources of information
Potential consumers are now faced with a fragmented and difficult to track down series of sources telling them about nursing homes.
They might start with:
- Individual aged care providers websites and brochures;
- the MyAgedCare website - information is focussed on costs, contact info and the status/certficiation of the home. Not much else is provided;
- the Quality Agency website for accreditation reports;
- the Dept Social Services website for non-compliance or sanction information;
- and finally, multiple feedback sites.
This competing market in services for them is confusing and many will not go all the way down that path.
The proposed hub is going to be very interested in what services are available, what the standard of care and quality of care is and in what those who have experience of the service think. While it will be interested in how local services compare with others, its prime focus will be on the local services to that community. It will be well versed in where to go to look and will be there to guide prospective consumers. Its staff will have direct experience of the services in the community to add to the information given. Although there will be overlap, the documentation provided by these services will be an important resource for the hub.
A cooperative system
It is important to emphasise that the power and knowledge imbalance must be addressed so that discussion is on an equal footing. Also that this is an amicable non-threatening cooperative effort to get the best outcomes possible for consumers, many of whom are compromised by frailty and dementia - a good service for the community. People will disagree about how best to do that, but disagreement fuels reasoned discussion and when needed, research in order to resolve issues and get there.
If I engage an architect to design and supervise the building of my house, I spend a lot of time with him/her and take an interest in the building. We both want the same thing and work amicably together. I will make sure that I get what I want and control some of the artistic excesses I don't like. We would have to be pretty incompatible and I would have to be very dissatisfied to fire him – but I do need to have that option.
Having a grand idea is only a beginning. By setting out where I think we want to be, why I think we want to be there, and what that could achieve I hope I have made this beginning. That is the easy bit.
The ideas need to be set against other ideas, debated, modified, honed, trialled and those that don't work rejected during this process. If so we will need to start again and continue until we come up with the best we can which should then be adopted.
A society that is apathetic, disinterested and often ageist will have to engage across generations, confront its biases and preconceptions, decide what it wants and then devote time and energy not only to getting there but in making it work. They will need to stay involved and continue to support it.
Whatever we decide, we need to start on the road because aged care is not really working for far too many now.
Inside Aged Care: An in-depth analysis on another website
When information is encountered in isolated bits and pieces it can be difficult to see what is happening. It is only when a large amount of information is brought together and examined that links and patterns begin to appear. You are then able to make hypotheses and examine the material to see if they are valid.
I gathered a large amount of material on my Corporate Medicine website written in bits and pieces between 1996 and about 2008. There are over 600 web pages examining the conduct of health and aged care corporations in the USA and Australia over a period when there was strong competitive pressures and consolidation similar to what we are seeing in aged care today. The story of the corporatisation of health and aged care is told in quotes from available material. That site is now cumbersome and the format dated.
Aged care is rapidly developing into a strongly competitive marketplace. I have spent the last several months going through large amounts of recent material to see whether what I found in the past and wrote about is reflected in what is happening in aged care. While doing that I wrote a number of web pages analysing the sector in some detail and illustrating it with examples and quotes from available material. I have put that onto my own website.
On this web page, I have simply summarised my assessment and conclusions and shown how my suggested "solution" might work.
Many will not like those conclusions and may well be angry. We do need to have a debate about them and I do want people to see if they can destroy them and the conclusions I reached. That is the only way to be sure they are valid. They are compatible with international data. It would be better if we had hard Australian data to finally confirm or refute them, but that is not there. The proposed hub would collect that data but, because it also addresses and corrects the problem, the data collected may not fully reflect what is happening now.
But I want this website to be a constructive one where we talk about the sort of aged care we want and how we can get there. I have therefore put those more analytic web pages on a separate website of my own which I have called "Inside Aged Care".
The Inside Aged Care web site is now open and the first three major sections in the analysis are live. The remainder will go live as soon as they are completed.
Inside Aged Care Home Page
A. Introduction - The first part supplies background Information There are linked pages that
- Aged Care Roadmap criticises the Government's proposed roadmap and compares it with the proposed Community Aged Care Hub
- Speak out if you dare explains the difficulties in criticising government and powerful companies in more depth.
B. Aged Care Analysis The second part is a critical in depth analysis of the aged care system showing how the proposals made would address the many issues raised. This page is an overview. The following linked sections are now live
- 19 years of care closely examines what has happened in aged care documenting the many failures.
- Aged Care Marketplace examines the way in which the market in aged care has operated and created these problems.
- Cultural perspectives looks at the psychological and sociel processes that create what I have called a culturopathy, It gives multiple examples in vulnerable sectors including health and aged care. It looks at the consequences for the not-for-profit sector and for society as a whole.
Links to further sections will be added when they come on line.
I am aware that the sort of analysis I have applied to aged care has not, as far as I know, been applied in the same way, but am reassured that others have said the same things in situations that are not dissimilar.
I am fallible and if I have arrogantly stated my views it is to stimulate a response and discussion. Please comment, criticise and suggest - but please do so with evidence and logic. Don't be put off because you feel inadequate and don't know enough or because you don't understand everything I have said. Engage and say what you think and what you like. By discussing and having others respond you learn. We all have to start somewhere and what you learn now is going to help you later when you really will need it.
Thanks: Finally I would like to thank Lynda Saltarelli with whom I have corresponded and discussed aged care issues over the last 8 years. She has shared with me the aged care material that she has collected over that period and we have discussed its significance. We have worked together on submissions to aged care Inquiries.
Lynda sourced the vast majority of the material on these web pages. While the words and ideas are mine, Lynda is responsible for vetting, suggesting, criticising and proofreading the pages. The layout and structure of the web pages are entirely hers and are a testament to her skills.
Without Lynda, these pages would not have been possible. Thank you to Aged Care Crisis for allowing me to air views which may not necessarily be their own.
My brother Ian has kindly read an earlier version of these pages, used his writer's skills to suggest grammatical corrections and indicated where clarification was required to make the points and illuminate the issues. The errors, which I am sure others will see, are those I have made since then