On this web page and the linked pages, I attempt an in-depth analysis of the Australian aged care system going into this in increasing depth in the linked web pages. I also look critically at our political system and why it has failed aged care and those who receive it.
The story of aged care is one of a cycle of failures in care and endless government inquiries - none of which confront fundamental issues or make the sort of fundamental changes that are needed to address the failures. For those who have followed developments in aged care and made submissions to these inquiries over the last 19 years, it has been an endless succession of Groundhog Days.
The first slider 19 years of Aged Care (below) links to a page which looks at some of the worrying things that have been happening in aged care. This is followed by a slider that outlines the issues in the aged care marketplace. It links to an in depth analysis of this marketplace looking at the social dynamics and their impact on the different types of providers. It explains why the marketplace policies for aged care create a dangerous high-risk situation for the frail elderly and their families - risks that are carefully explained to investors who can choose, but not to the residents or the community who are given no choice in a system that claims to be all about 'choice'.
In the following section 'Cultural Perspectives', I describe my analysis of the system and use examples to illustrate its utility. I explain what I mean by 'culturopathy'. I look at the hollowing out of communities that is a consequence of government policy. Pages in this section examine the response of the not-for-profit sector when forced to operate in a competitive marketplace. To survive and prosper, they have to embrace and identify with ideas that challenge the very reason for their existence.
The remaining sliders and the linked pages go more deeply into both our aged care system and the dynamics of our political system explaining where fundamental problems lie. It does so from many points of view and in doing that, argues that our political thinking has reached a stage called 'paradigm paralysis' and our aged care system, if not already a harmful culturopathy, is well down this path. On these pages I explain how I think my proposal for a Community Aged Care Hub would help to reverse this process.
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19 years of Aged Care
Aged care in Australia was turned into a corporate friendly "competitive marketplace" in 1997. Over the 19 years since then, there have been recurrent confronting scandals and continuous lower level unhappiness from staff, relatives of residents in nursing homes and sections of the community that have looked closely. Both the complaints accreditation systems have been heavily criticised. At the same time, politicians and industry supporters are claiming that we have a 'world class system'.
The linked pages in this section look at the warnings that were ignored, early identification of problems and the proposal to change direction that no one was interested in and the endless cycle of inquiries, failures and regulatory patches that followed, as the fatal flaws in this system were ignored.
The page also looks at the cries of pain coming from staff and residents at the coalface who know and identify the problems - the disillusionment, the helplessness and the pleas for someone to do something - but the community is deaf and no one else is listening.
Finally, the linked pages look at the paternalism in an industry that wants to educate their critics so that they come to understand that they are wrong. It shows what is happening in aged care and what is being said about it.
The Community Aged Care Hub
The role of the proposed Community Aged Care Hub will be to go into the nursing homes to find out exactly what is happening and what lies behind all of these reports, make information available and constructively assist in addressing issues. If it becomes necessary, it will have the power to put an end to inappropriate thinking, policies and practices.
In this section I do refer briefly to the way this proposed hub might address some of the issues, but this will be explored more fully in subsequent sections.
Someone hasn't got it right and it is clear that we don't have the information we need to tell us what is really happening. We can only fear the worst. It's time to sort this out.
Learn more: For a brief outline of these failures, visit 19 years of Aged Care
The Aged Care marketplace
Common sense and nonsense: A functioning market rewards those who serve us well and puts those who don't out of business. But a market that fails because there is no effective customer does the very opposite.
It rewards those who exploit the vulnerable customers who don't have the power to protect themselves, and puts those who try to serve them out of business. That's what market theory and our common sense knowledge and experience of human behaviour tells us will happen. Then there is our history, and the intellectual wealth of years of social theory and research that is simply ignored, when creating a market without effective customers.
People have been exploited in almost every market sector in which customers are vulnerable. We might well ask how any community of sensible beings could have set up something so stupid? As I will explain later, it is a combination of ideological belief and culturopathy. Together they work by ignoring most of what we already know and replacing it with illusionary beliefs.
I will show how it works to make things like this happen - in our less than logical world. Its not something new. It has been around a long time but we never learn from our experiences.
To my knowledge, those who think independently have been trying to tell people this since the 1980s but true believers are deaf and blind to the consequences for others and for society as they bask in the economic success of their policies. These critics are getting increasingly frustrated. That frustration shows in the writings of economists like Ross Gittens who writes for the Sydney Morning Herald. After berating the blindness of current economic thinking he says:
But to frame them (Health and education) as part of competition policy is an old economists' trick: take an area that's always been outside the marketplace and marketise it. Take the world as it is and make it more like the textbook assumes it to be.
Apply the economists' two magic answers – getting the incentives right and introducing competition and choice – and everything will fix itself without the economists ever needing to come to grips with the causes of the particular inefficiencies that are causing the problem.
Brilliant. But often disastrous. Think of the string of stuff-ups that have followed the econocrats' efforts to contract-out the provision of government services.
Source: Let's not repeat our many competition stuff-ups post the Harper review The Sydney Morning Herald, 30 Nov 2015
The corporate marketplace: Enthusiastic and dedicated entrepreneurs focussed on what has become an exciting market game are unaware of what they are doing. They think it is designed to work and is working. The linked pages look at the dynamics of the game, where growth is the goal, monopoly the vision, and a pot of gold the reward.
The tools are: war chests, profit streams, loans, floats, stakes, mergers, takeovers and IPOs (Initial Public Offerings).
The players are: government, politicians, companies, private equity, turnaround specialists, brokers, analysts, consultants, investors and managed funds - vast numbers of people.
The only participant who is not a player is the customer: In aged care it is the frail and demented in our society. They are the source of the money that the players in the game need to meet their objective. They have to keep acquiring more customers if they are to stay in the game, because most of them don't last very long. There may not be much left to care for the consumers after all of the players have taken what they need to enable them to compete successfully and reward themselves for doing so.
To be fair, there are players in the game who have maintained the illusion that the object of the game is to provide care and have tried to do so. It could be even worse and in some sections of health care in the USA it was. The problem is that, in this market, those who try to provide good care are playing with one hand strapped behind their backs. They don't perform well and are steadily eliminated. That is increasingly happening to those that don't focus on the real objective of the game.
The Community Aged Care Hub: The section linked to and the pages examine how the tools and players interact and how the pressures and excitement builds in the game. To a large extent, this is at the expense of the aged consumer. It goes on to show how the proposed hub plans to introduce a new powerful player - the community customer, on the side of the consumer, and how it will change the rules so that the goal of the game is care. The players who lose sight of this goal will be the losers and be eliminated. That is what the market is supposed to do. The major objective is to make this market work by having a powerful and knowlegable ally standing beside the customer. But the hub should do much more than this. The remaining pages in the section explore this marketplace in more depth.
In subsequent sections, I will look at the interplay of social forces and the development of the illusions that have propped up this system and allowed it to continue in spite of its logical and obvious consequences.
I will analyse how all of the enthusiastic and dedicated players have worked together to keep its deficiencies under wraps and maintain the illusions on which it is based - the illusions that have helped to anaesthetise our communities and stop them from reacting to the suffering experienced by some of its members. I will look at how the hub will help by sorting this mess out.
Learn more: The Aged Care marketplace
Cultural perspectives: An approach to the problem of Aged Care
Belief systems: During most of my life I have had to deal with the consequences of different belief systems, some of which I was initially a part of. I have tried to confront some of the things that are done in their name. Changing patterns of thinking in health in four different countries have engaged my interest during this time. Developments in aged care in Australia have become particularly worrying over the past 19 years.
Culturopathy: My interest is in the way different patterns of thinking develop and how they come to be applied to situations where they don’t work, and then cause harm and suffering. While very common, we don't have a catchy name to use and this makes writing about these patterns of thought difficult. We fail to recognise the problem each time it appears so each occurrence appears to be unique.
I am going to use 'culturopathic' as a descriptive term for 'cohesive groups of people whose patterns of belief and actions are harmful for society'. They impair the operation of society and impede democratic processes by their mode of operation. They generally maintain their position by controlling the way information is collected and publicly presented.
This approach throws some light on what has happened in many parts of society over the years. In this section I look at how culturopathic activities have flourished in our capitalist system and how they have impacted those sectors where people are vulnerable, including aged care. Capitalism is distorted and distorted so that some are served while others are harmed. I give multiple examples to show where and how things go wrong. I show how extensive the problem is and how vulnerable we all are.
Identifying with culturopathy: When we are part of a system, which behaves in a culturopathic way, particularly if we are successful there, we identify with it and come to believe in it. We often don’t see what is happening and try to explain away things that go wrong. Outsiders looking in can, and often do, see more clearly. I don’t have direct experience in aged care but that can be an advantage. You can see things what others have not thought about because they are too close to it or because they are blinded by their success. You can contribute by making useful suggestions.
The for-profit providers: The majority of this group of providers have entered the sector in search of profits. The larger organisations serve investors and their primary responsibility is to their shareholders. Their duty is to exploit opportunities to make a profit and this is an impersonal mechanism. They are constrained by an effective customer and an active and powerful civil society. When these are ineffective then any vulnerability in the system will be exploited. The market will capitalise on vulnerabilities whether these be customers, employees or regulatory weaknesses regardless of the consequences for others. This section explores this with many examples to show that this is how the free market operates and aged care is simply one of many examples.
The dilemma for not-for-profit organisations: Not-for-profit groups come from a tradition of cooperative service to the community and a focus on the common good. They are now faced with having to operate and compete in an aggressively competitive market focused on profitability. They have to find some way of working in this very different environment. If they can't make enough money by providing the sort of care they think is needed they will either go under, or be acquired by someone who can. To survive they must behave in the same way. They have to find some way of justifying this to themselves.
Not-for-profit organisations have coped by increasingly thinking and behaving like for-profit corporations, but this is not easy for them and in the process their humanitarian mission, and their roots in the community, are lost. Increasingly, the distinction between for-profit and not-for-profit is becoming blurred.
Impact on communities: One of the consequences of a competitive market system and of a focus on central government is that organisation and control is moved away from local communities. This results in a loss of skills and knowledge, a loss of interest and as importantly of confidence. This has been described as a hollowing out of society and ultimately this weakens civil society and makes it much less effective. This limits the capacity and willingness of citizens to exercise their role and responsibilities as citizens. It limits the capacity of civil society to play its important role in democracy which is consequently undermined. The international open government movement seeks to address these problems.
The hub: The proposed Community Aged Care Hub would not only act as an effective customer, it would re-build civil society and give it the power it needs to fullfill its important responsibilities in our capitalist democracy - at least as regards to aged care. It would directly support and advise the customers giving them the knowledge and power to play their role and get what they need from the market. Because it would be actively engaged with providers, it would constrain their excesses, modulate their thinking and insist that they serve the community and its values. Not-for-profit’s missions and the values on which they were built would be supported. The relationship with the communities that they grew out of would be restored.
To explore these "cultural perspectives", see examples of culturopathic behaviour and follow the reasons for the suggested approach to solving our problems in more detail, visit the linked pages.
Learn more: Cultural perspectives
Widely contrasting views: Conflicting and incompatible views
Aged care is perceived very differently by government and providers on the one hand, and many nurses, doctors, academics, families, and community members, who have looked closely at what is happening in the sector, on the other. They cannot both be right. We cannot have both a 'world class system' and one where there are massive failures in care, where those who voice concerns are silenced, where the oversight and regulatory system is flawed, and where no effort has been made to collect objective evidence on which to base a reliable assessment.
Those who have blown the whistle on bad care have been threatened, fired and their careers ruined. Academics who's have found extensive problems in the provision of care have been attacked and attempts made to discredit them. Except for that provided by the criticised academics, there is almost no reliable evidence available to decide who is right.
A situation where there are contradictory views coupled with both a failure to collect the data needed to resolve them or enage effectively, is strongly suggestive of a culturopathy. Situations and cultures develop where the paradigms (patterns of thinking) that dominate the sector are not appropriate. As a consequence, society and/or its members are harmed. While evil people, and those whom psychologists have described as 'successful sociopaths' can and sometimes do capitalise on the opportunities this creates, most participants are true believers who are genuinely highly motivated by the paradigm. Some have built stellar careers in the system. They too, are victims and face consequences when the system finally breaks down and they are held responsible.
In a culturopathy, challenging data is not collected and what is made available is controlled. Being challenged is distressing and believers can and do respond angrily, rejecting arguments out of hand and attacking their critics.
The pages in this section explore what is happening in the sector to examine these differences by looking at the views expressed:
- by politicians/industry and aged care critics,
- by families and nursing homes,
- by staff and management,
- about financing by the industry and critics,
- by the professions and government and business,
- by industry and others
- about registered nurses and
- minimum staffing levels,
- by not-for-profits and for-profits and
- finally between provider organisations and academics
These wide differences and the failure to collect data to resolve them is indicative of a culturopathy. The role that the Community Aged Care Hub would have played in each of these situations - in preventing them, addressing them or assisting in resolution is described.
Learn more: Widely contrasting views (Web page not live yet)
Theory and Research in aged care
On this web site I am trying to examine the problems in aged care by examining it from many points of view in order to conceptualise the problems in different ways and see how the issues raised might be addressed.
There is a rich research literature exploring the nature of our society and of aged care within it. This studies our system from different theoretical perspectives. This depth of knowledge contrasts with the disregard of this research in the development of aged care policy.
Neoliberalism and the Post-truth era: Much of this research focuses on the neoliberal political agenda – policies that include free markets, micro-economic reform (competition and efficiency) and managerialism (top/down structured control). Competition and efficiency are key concepts and driving forces. Incentivisation and marketing are key strategies. Aged care has been ‘reformed’ within this discourse (ie general framework of ideas) and there has been intense criticism of its adverse consequences for care.
The linked section
In the linked section I look briefly at the history of markets leading up to the development of neoliberalism and its early abandonment of social responsibility - to the customer and society. This was on the basis that this was socialist and so evil. More recently there has been intense criticism with many claiming that neoliberalism is on the way out. With nothing to replace it there is a policy vacuum and many will cling to its vestiges.
It is now clear that neoliberal policies have been deceptively oversold and are not delivering the claimed social benefits. Deceived citizens no longer believe what anyone tells them so that even science is no longer accepted. This has created the ‘post-truth era’ characterized by fake news and political instability. Emotion readily trumps common sense and evidence. Extremism has flourished. Our society and our democracy is challenged. It is not clear what the consequences for aged care will be.
Sociology: There is a brief look at sociology as a theoretical discipline. There is a summary of the more recent insights of French philosopher Michel Foucault. He used the concepts of power, discourse and governmentality. He explained how knowledge gave some the power to control what was included in the discourse and more importantly what was not permissible there. In doing so the way in which those engaged in the discourse thought and behaved was controlled. By setting the framework for their thinking the discourse entered their souls and governed them – or more correctly made them govern themselves. These insights have provided a perspective for some interesting research.
I am particularly interested in the way words, ideas, and processes readily become tokenistic. They are used to claim excellence within the frame of the discourse where this is required. They become a token for something that should be there but is absent, or is being largely overlooked. The real situation would challenge the discourse.
Macquarie University: A body of research associated with the department of sociology at Macquarie University warned, in the 1990s, that free markets were not an easy fix for aged care. Over the years they have studied the history of aged care and the ideas that have driven policy and impacted care.
Their studies have focused on the nature of care, on care in the community and ageism. These authors have been particularly interested in the relationships surrounding care, the impact of power and the nature of dependency and interdependency. This body of work defines the sort of care that is needed and the conditions needed to provide it. In doing so the authors repeatedly confront the difficulty of meeting these objectives and providing the sort of care their research indicates is needed within the system created by the neoliberal discourse.
South Australia: A second strand of research centred on South Australian Universities has focused on nurses and the care they provide in hospital, community and aged care. This largely focuses on the way nurses time, and how they spend it, has become the central focus of the neoliberal management agenda. Analysis using Foucault’s understanding of power, discourse and governmentality reveal the way that nurses have come to own and adopt the neoliberal discourse in their work, working within it, governed by it and identifying with its objectives.
Where once the focus of discourse was on care it has now shifted to the use of their time to meet the objectives of their employer. While ‘excellent care’ is what they are required to deliver it is clear that when there is insufficient time this readily becomes tokenistic. Several other studies focus on the increasing rate of ‘missed care’ care that is not provided because there is no time to do so.
Recent work in Australia looking at the amount of time that is required to provide good care and at data from the USA is contrasted with the very poor staffing levels in Australia. These point to the validity of the many allegations of poor care and the criticisms made by nurses at the bedside. These were escibed in the section 19 years of care. These were not isolated incidents or complaints by misfits in a world class system. They were red flags to a system in crisis.
Insights from Foucault: During the 1990s and early 2000s I studied and wrote extensively about the health and aged care systems in the USA and Australia tracking the patterns of thought through corporate documents, statements by leaders in the sector and press reports and relating them to the extensive exploitation of vulnerable patients in order to defraud their insurers.
I have re-analysed some of that work broadly using Foucault’s concepts to show how the corporatization and marketization of these sectors were driven by neoliberal discourse originating on Wall street and in politics. It was disseminated through financial advisers into these sectors spreading down to every level of the companies including doctors, nurses and even patients who believed that what they were getting was excellent care which was anything but. The nature of the frauds are explained. The discourse and its unchallenged acceptance is readily tracked from the USA into Australia.
Most revealing is the impact of the discourse on regulation in the USA and Australia. It shows clearly how regulation in both countries was captured by the neoliberal discourse and was managed and controlled by true believers. It readily explains why regulation has been tokenistic and singularly ineffective in both countries. Its primary unstated role was to protect the discourse, market the excellence of the system created and make the defense of its failures look legitimate.
Regulatory Capitalism: The neoliberal discourse sees regulation as intruding and harming the successful performance of markets and the policy is to reduce it. While the belief is still maintained in the discourse its failures have led to such extensive regulation that researchers, particularly criminologists have called this ‘regulatory capitalism’. This regulation is largely managed and controlled by government, government appointed independent agencies, or industry itself. The extent to which it has been captured in other sectors is not clear.
In their research they have sought ways to improve regulation. One of the useful observations has been the effectiveness of one on one, on site interaction between regulators and regulated providers – the personal interaction and the pressures generated there.
The argument here is that when looked at broadly, a social system that depends on extensive formal external regulation to control its excesses is a social system that is defective and not working. Functioning social systems use the day to day interaction between people to stigmatise inappropriate thinking and so regulate themselves.
Socially constructed reality: In the mid 1990s insights led to an understanding of the way in which we as social beings interact with the world out there and then in our minds and in our discourse with one another built a worldview that enables us to understand the world we lived in and so give our lives meaning. Several different theoretical perspectives and research projects developed from this.
This led to insights into the stresses we experience when our worldview becomes unstable and our meaning systems are challenged. Research examined the way we respond to these situations and explained why we are so vulnerable to ideology. There are insights here which are useful in understanding what has happened and when considering the sort of system we would like to have in aged care.
The context of our lives and the expression of our genetic inheritance: This section looks back at the rise of behaviourism (the use of incentives and disincentives to influence behaviour) in the 1960s and its fall from grace as its adverse educational consequences were recognized. It was a call to more primitive aspects of ourselves – the animal in us. It was based on works done on rats and its critics were soon aptly described it as turning people into rats.
'Incentivisation', the use of incentives promised if goals are attained and disincentives threatened if goals are not attained, has been a central plank of neoliberal management. When the many problems in the marketplace and the frauds in the USA are examined incentivisation, particularly kickbacks of all sorts, can be seen to have been a driving force.
But there are those who will follow the incentives blindly while others are able to see the adverse consequences and whose sense of responsibility will cause them to refuse, resign or occasionally blow the whistle.
In looking at who is likely to behave badly we can consider our genetic heritage. The example I use is the warrior gene (one of many impacting on behaviour) now detected in sociopaths whether mass murderers or successful businessmen who take people for a ride. Four percent of senior managers carry the gene. But the gene’s expression is socially determined by our upbringing and the context within which we find ourselves.
So the argument is that our genetic makeup and our upbringing are factors that play a role in determining whether we will behave like rats when we are tempted or reflect first and decide to behave responsibly instead.
An aged care roadmap: The research and the theory help us to look at the problems and potential pitfalls in the government’s planned aged care roadmap. We can compare this with the discourse around a proposed community-centric roadmap and see how it measures up. It seems to address many of the problems in the neoliberal free market based system. It provides a context where the attributes and programs that the research indicates are desirable can be developed.
This section explores all these issues.
Learn more: Theory and Research in aged care
Data collection: The importance of information
Information and culturopathy: As I indicated earlier, culturopathy is only possible and can only be maintained by keeping control of the information available and selectively interpreting it. Objective data in aged care in Australia is not sought. What is obtained is tightly controlled by government agencies. There is little attempt to reliably evaluate it. We have an opaque system and not a transparent one.
Getting good data: The only way to ensure that we collect data accurately in vulnerable sectors is to put the collection of data into the hands of the consumer and, if they are vulnerable and lack power, then into the hands of a proxy customer acting for the consumer - ie, in this instance in the hands of 'civil society', the community itself. This information should be widely shared so that its significance is interpreted and resolved by informed discussion from many points of view.
Shared data: The shared collection and interpretation of data is essential for curbing culturopathic activities and the success of the community hub. Accurate data is essential for providers, for the community hubs, for customers, for identifying areas for improvement, for research, and for policy. Without it everyone is working in the dark and attractive illusions are too easily accepted as valid. Without accurate data, we are simply going to have more of the same and that simply cannot be an option.
Changes to collecting data: In response to the wave of complaints, the current government is pursuing new ways of collecting data and claiming this will give the community what it needs. It is being collected by providers. Its interpretation and publication is organised by government. In a culturopathy this rarely works. Even with the best of intentions, the pressure of the illusions, the power structures in the sector, and the patterns of behaviour will be at work behind the scenes. It is likely that we will be given an illusion of progress, but that little will change.
The linked web pages:
- look at the failure to collect useful data
- examines the problems in the accreditation process and its failure
- looks at what is happening with the complaints system
- it examines the government's responses to the community's unhappiness including
- the introduction of quality indicators
- the South Australian trial of reduced oversight, self regulation, delegation of complaints back to providers and some community input
- the proposal to outsource accreditation to the market
- the changes to the complaints system
- examines the problematic way industry groups, government and community are trying to collect and use consumer feedback.
With the exception of some of the feedback, all of these projects depend on the aged care industry to collect the data itself and for government to publish it. The entire process remains largely under the control of the providers, the government or their appointees - the family of 'believers'. Transparency has not been addressed. Consumer feedback has become a fragmented and commercialised industry with many weaknesses that impact on its utility.
The hub: The proposed Community Aged Care Hub would work with providers in collecting data including Quality Indicators and be responsible for this. It would work closely with providers in doing so. This would ensure its integrity. The central section of the hub structure would be responsible for the interpretation and publication of the data collected by each hub so ensuring total transparency. The hub would be in an excellent position to assess and comment on the less tangible parameters including quality of life and the culture within facilities.
Accreditation and complaints handling would be closely coordinated with data collection by working through and with the hub. The hub would address the weaknesses and vulnerabilities in the consumer feedback system by recruiting and vetting those giving feedback and by becoming the primary customer.
To explore the way in which data is collected in aged care and what is being planned without consulting us follow the link.
Learn more: Data collection (Web page not live yet)
From think tank to bedside
The radical economic ideology that is impacting on aged care today had its origins in think tanks in the UK and the USA during the 1970s and early 1980s. The belief system became policies in those countries in the 1980s and as the economic benefits became apparent belief in this system grew and it rapidly became global. When measured by sharemarket and other marketplace parameters markets in vulnerable sectors were particularly successful and there was a boom.
The market was believed to be self-regulating and universally applicable. It was argued that the market and not government should provide services to the community. The US Sun Healthcare's founder, Andrew Turner, one of the strongest proponent of these ideas in the aged care sector came to Australia. He indicated that government should butt out and let the market sort things out. The need for an effective customer and/or regulation was ignored.
Anything that restricted the market's freedom was seen as harmful and 'liberalised' - ie, removed. Regulations that previously protected the vulnerable were reversed. The impact has been felt across all those sectors that were vulnerable to exploitation starting with the giant banking institutions on Wall Street in the USA and spreading through health and aged care. There have been ongoing major scandals and frauds in multiple sectors and the vulnerable have been systematically misused.
Major changes were made to health and aged care following the election of the Howard neoliberal government in 1996. Health and aged care were turned into markets. Health care survived relatively intact as doctors stood their ground and used the power they had to become the proxy customer acting on behalf of the vulnerable consumer.
Aged care was less fortunate as doctors had no power here, the consumers were ineffective, and the community sidelined. Particularly worrying was the removal of all effective oversight from the sector. This was compounded by the control of the little information that was collected. The new neoliberal government is intensifying the pressures to consolidate and corporatise.
There is more about the background and nature of the ideology on the linked page. This then links to in depth pages that:
- examine the origins of these theories and the restructuring of society into a hierarchical system driven by managers and consultants.
- describe the way in which civil society was marginalised, losing its knowledge, its credibility and so its interest in the affairs of the community and government. It stood by as its functions were delegated to government and market. It is no longer filling its role in our democracy. Citizens are unable to meet their responsibilities as citizens and have lost interest in trying to do so - expecting government to do everything.
- describe the way in which the 21st century open government movement (a partnership between civil society and government) and the related participatory democracy movements seek to address these problems by rebuilding civil society and enabling citizens to reclaim their roles and build social selves by meeting their responsibilities.
- describe the introduction of the belief in markets into Australia and what happened. The rather different way it played out in the related health care sector in Australia is contrasted with its introduction into aged care.
- describe the "liberalisation" of the aged care marketplace by removing the vetting of owners, the abolition of oversight and collection of useful data. At the same time the opacity of the new system shielded government from criticism and marginalised the community. In essence all effective constraint was removed and the market was left to provide aged care as it saw fit in the belief that this would work and that market processes would correct any problems .
The hub: The proposed Community Aged Care Hub can be seen as part of the open government movement. It seeks to introduce total transparency and rebuild civil society by involving citizens and giving them important and responsible roles in managing the affairs of the community. It can also be seen as a participant in the participatory democracy movement within the aged care sector. It creates lines of communication between the community, government and the rest of society. It creates a structure in which innovation and policies can develop within society near the coalface and then be fed into the political decision making process.
Learn more: From think tank to bedside (Web page not live yet)
My examination of what has been happening in vulnerable markets has led me to have a jaundiced view of the application of incentives and disincentives in vulnerable sectors. Forces which are generated by incentives and disincentives can drive people towards socially dysfunctional practices. Many are built into the structure of competitive corporate markets in vulnerable sectors.
Modern management practices (micro-economic reform) based around incentivisation compound this. Businesses often cooperate and entice others to refer to them or support their activities using incentives or mutual agreements. These are seldom in the public interest and are often harmful. In my view, this is a form of misapplied behaviorism, a theoretical system that critics suggests can make people behave like rats. I argue that that happens.
Incentivisation is a major factor in encouraging and fostering culturopathic behaviour particularly in vulnerable sectors like health and aged care.
The contexts within which we live attract and support the people whose personal attributes allow them to succeed there and selects for them. I look at neurological, genetic and cultural research into people who behave badly and suggest that contexts where the incentives are dyfunctional select for people who will respond to the incentives rather than to their consciences and so more readily behave badly. A culturopathy selects for people who are not reflective and who will identify with the beliefs, particularly where people are vulnerable and the ability to look past their suffering brings personal success. A perverse sort of social darwinism operates where the people who should not be there succeed and those who should be there go elsewhere..
The first in-depth page looks at the relationship between behaviourism, incentivisation and kickbacks. It looks at the genetic and cultural backgrounds that create a diversity of personality types. The wide range of attributes available across the population enables some humans to adapt, succeed and emerge as leaders in almost any context in which our species finds itself including in culturopathies. This has an evolutionary advantage but not a societal one.
On the other linked Looking differently pages, I take a rather different look at several of the things happening or planned in aged care and consider the likelihood of these being dysfunctional and creating pressures that result in the abuse of trust and the exploitation of the vulnerable. Consider where the incentives and disincentives lie in these situations.
- the manner in which 21st century concepts of personalisation including user empowerment and user control which are themselves a response to 20th century thinking are being introduced within the context of this same centralised 20th century free market managerial thinking. A similar approach in the UK is already in trouble. The risks of fraud and manipulation of Consumer Directed Care (CDC) to exploit the vulnerable have been ignored or denied. It is now recognised that community participation and control is critically important for the success of community projects and the continued involvement of the community in the lives of the elderly is a critical factor in sustaining their quality of life. Community involvement in the process has been absent or at best tokenistic.
- company responses to government policies and calls for innovation. The argument is that innovation coming from the corporate sector focuses on what will be profitable and is too often implemented without evidence or debate. Innovation coming from the community (eg. the hub) focuses on need and genuine improvement and then finds ways of testing it, collecting evidence and funding it.
- risks to the elderly from an incredibly complex system incorporating an aggressive market. It is easy to fall through the cracks. A better integrated local system is needed to make the system much more flexible and responsive to individuals and their situation so they do not become enmeshed and crushed by complex processes.
- the way in which industry looks at shoddy operators training nurse aids but ignores those who run nursing homes - the 'pot calling the kettle black'
- attitudes revealed by Commissioners in the 2010 Productivity Commission review into aged care, and
- the way that difficult but important issues like standards of care might be put on the back burner while easier and more financially profitable objectives like offering extra activities to improve quality of life are pursued.
Clearly, the proposed hub is intended to create a context where dysfunctional practices leading to exploitation are soon identified and seen to be self-evidently inappropriate. They are resolved if possible by discussion, or if recalcitrant by the market forces exerted by the hub as customer. I look at how the hub could be incorporated into significant advances like Consumer Directed Care (CDC) to ensure that they work for citizens.
Learn more: Looking differently (Web page not live yet)
Government Policy (and Aged Care): Illusions, smoke and mirrors
The underlying theme on these web pages, is that aged care is fatally flawed because it does not comply with the fundamental principles needed for a market to work. In a successful market, the two marketplace participants have conflicting priorities. The benefit comes from a balance of power in which the customer has to have the upper hand. When they lose that, then things too often go awry.
Aged care policy is based on the illusion that you do not need to have an effective customer for a market to work. Supporting that is the illusion that regulation and the imposition of penalties is an effective means of changing culture and controlling behavior. Then there is the illusion that accreditation is an effective form of regulation - illusions one on top of another so that the first illusion can be maintained. The evidence is that none of these are valid.
When you use illusions to do something in the real world, they inevitably bump up against something that is real. In order to support the illusion and do what the illusion dictates, a cascade of additional illusions are developed - a new one each time the real world intrudes until we have a taller and taller house of illusionary cards.
Sociologists study the ideas around which cultures form and one of the things they teach their first year students is that although ideas may be illusionary, when they are accepted as being real, then the consequences are real. The information coming out of the aged care system is that the consequences for many frail, elderly Australians and their families have been horribly real.
One of the most dastardly deeds of the Howard government in 1997 was to quietly, as an unnoticed part of their reforms, abolish the probity requirements that all those involved in owning or operating aged care facilities had to meet.
Not only did these provisions protect the elderly from the unscrupulous, but they clearly set out and "objectified" the morality, norms and values of the community to which those responsible for care were expected to adhere.
Probity requirements were replaced by an Approved Provider Process which removed the protection and sent a very different message about what was expected. The illusion on which the Approved Provider Process was based, was that controlling owners had no influence on the care provided. It was the managers and 'key personnel' in the subsidiaries providing services that were responsible for care and therefore required to be assessed and approved. In any event they argued, they all had to pass the accreditation standards and that would enforce good care.
In this section, I look at the way ideological beliefs operate and the way many are based on illusions. I then use the change to probity requirements to describe how layers of illusions were developed in aged care.
I use a 12-year struggle to get information about how the Approved Provider Process actually worked to illustrate the cascade of illusions and the way they are used to bolster what was done and shore up the primary policy illusion. I make a list of some of the illusions generated to support this process. These pages explain why paradigm paralysis has occurred and makes any useful political changes to aged care impossible for politicians.
The performance of owners of some Australian aged care businesses as well as international and local studies are used to debunk the illusion that underpins the Approved Provider process.
The data clearly shows that the controlling owners, rather than the key personnel they appoint, have the most impact on care. The evidence indicates that not-for-profit groups provide better care than for-profit groups.
Private equity groups provide the worst care of all and it gets worse the longer they own the nursing homes. This is what you would expect if the pressures for profit were the main determinant of the sort of care given and the quality of life of the frail elderly. Rather than improving care, marketplace competition erodes it. Efficiency becomes a justification for practices that not only compromise care, but obstructs the day to day interaction that we all require to make our lives worth living.
With care and profit coming from the same pay packet, its hardly surprising that strong competitive market pressures incentivise businessmen to take more and more from care and then find ways of justifying it. That we need scientific studies to tell us the obvious, is an illustration of the power of illusion and how far Australia is down this path.
The hub: It is other people in the community who have real experience and knowledge that identify illusions and challenge them ensuring that culturopathies are nipped in the bud. Illusionary light bulb ideas usually arise in small sectors of society even within narrow disciplines in universities. When they become larger then it is the wider community, civil society, that has to control this using its power, broad knowledge and the common sense developed by the wide and diverse experience of life in the community and their knowledge of human history. This requires a well structured, knowledgeable, well educated and influential civil society and its absence has been a major factor in 20th century failures. This is one reason why the 20th century has been such a chaotic and violent century.
The best way to prevent or address a culturopathy is to create an environment (ie context) in which a broad range of unconverted but knowledgeable people become involved in organising key activities together with the providers. This engagement needs to be done in a constructive manner where the issues and thinking behind present or planned policies are confronted at every turn and where believers are able to retreat and change direction in a supportive environment without losing credibility. This is what the hub is intended to do.
If the culturopathy is well established this breaks down and issues are unresolved. It then becomes a test of power. This is why the community aged care hub as the arm of civil society needs to have the power to put any facility or provider out of business when all else fails. It also needs to be well represented on any body approving providers of care so that it has the opportunity to investigate any applicant and veto any applicant that has not displayed the integrity required in the sector. By doing so, the expected paradigms, values and conduct required for the sector can be clearly spelt out.
Learn more: To explore these issues visit Government Policy: Illusions, smoke and mirrors (Web page not live yet)
Keeping it all in the 'family': Aged Care and Politicians
Doug Moran was the doyen of the for-profit aged care corporations, who had supported the Liberal Party so strongly in the 1996 election. Aged care policy and the 1997 Aged Care Bill was written by and for the corporate interests that had supported the party.
... Accommodation bonds are the key to investing in nursing homes, and provide just the kind of complexity and opacity that financial engineers like Macquarie love to exploit. The policy framework was set up in 1997 under then-prime minister John Howard with close involvement from the private sector, particularly the late Doug Moran ..."
Source: Meet the men cashing in on Australia’s aged care crisis, Crikey, 24 Apr 2014
Since 1997, politicians and the industry have walked step in step, making the same claims, and the same denials. There have been kneejerk responses to scandals, directed to giving the public the impression of a response, while still protecting the industry. The Labor Party has happily played along and been careful not to rock the boat. This was a political hot potato. Information from the market and government sources was tightly controlled.
... It's not complicated, the way business operates in Canberra. Political donation laws in Australia are so loose, it's not rocket science to see what is happening. Ten thousand dollars can be donated before anyone even has to declare anything. With political parties structured around state branches, in real terms it is more than $100,000 before anyone has to start declaring ..."
Source: Rob Oakeshott: How big business hijacked parliament - The Saturday Paper, 8 Aug 2014
With few exceptions, various Government Inquiries were conducted by those with a strong market focus and the aged care industry has been well represented on committees and given senior government posts. These included the Aged Care Commissioner in 2010 and as one of three Commissioners on the 2010 Productivity Commission Inquiry Caring for Older Australians. Both were labor government appointments. With few exceptions, there seems to have been someone there to protect the interests of the industry, but few, if any, to protect the aged customers.
Then there is the Approved Provider process that protects owners, who have criminal pasts or whose conduct is otherwise disturbing, from assessment of their suitability. Until January 2014, oversight and regulation was by the fatally flawed, supposedly independent, Aged Care Standards and Accreditation Agency.
All pretence at independence has now been abandoned and the Accreditation Agency has become the Australian Aged Care Quality Agency within the Department of Social Services, directly responsible to the minister.
The CEO of LASA (the body formed in 2012 to represent all the providers and to lobby government on their behalf), has simply moved over to become CEO of the Quality Agency. He will be closer to government.
It is worth noting that Tony Abbott, the recently replaced Prime Minister was part of the government that worked so closely with Doug Moran to set up the system in 1997. As explained on another page, it was structured to protect the government from criticism.
It may be that the market is now so powerful, that government must do what they are told. Perhaps the involvement of the market is so critical to meeting the aged care bulge that no government dare cross them.
To the outsider looking in, it is clear that government is more concerned with protecting the industry, and avoiding new taxes, than in caring for its citizens. In the current toxic political climate where 'No More Taxes' has become a political catch cry for electoral success, it is impossible to have a sensible debate about any sort of constructive funding.
... It has been put to me more than once by politicians and senior bureaucrats that medicine is too important to be left to doctors. I contend that it is demonstratively much too important to be left to politicians and senior bureaucrats ..."
Source: Aged failings - MJA Insight, Dr L Mykyta (experienced geriatrician), 2 Jun 2014
Dr Mykyta's words ring true. The science and logic of the caring professions and the community organisations that worked with them has been subjugated to a political ideology built on illusions. As explained and illustrated on previous pages this had resulted in "paradigm paralysis" and that means that political thinking is locked and political options limited.
But we need to understand that when government and industry are wedded to the same illusionary belief system and it is crumbling in the face of the real world, the only way to protect the belief system is for them to 'keep it all in the family'. Our first step must be to stop this. That is what the hub is intended to do.
The first page in this section: The linked page examines three paradigms (ways of thinking) that can be used to look at what is happening with government and industry appointments. They come up with different justifications and insights. These are "Government mandates" based on electoral success, "Keeping it in the family" a social process perspective and "The power paradigm". The latter looks at the influence those with power in the can wield. These include talkback radio hosts, newspaper owners and those companies and individuals with enough money to make large political donations, employ lobbyists or fund marketing campaigns that oppose or support political policies or decisions. This paradigm reveals that in our democracy, some of us are far more equal than others - so much more equal that we can dictate policy or even expect to be privately consulted before policies are approved. All have some validity and justifications. Together they provide many insights.
In an established culturopathy only believers are seen as being credible and are the obvious people to appoint. Doubters and critics are seen as outsiders and not to be trusted. In our society market leaders have more credibility and influence than others. In aged care it is the providers and the business groups that have support. Critics are seen as not contributing and are not supported. In the Howard era, senior groups that had been very influential in aged care but very critical of the 1997 aged care policy, lost their funding.
The peripheral pages: The three pages linked to from the first page in the section employ the "Keeping it in the family" paradigm to explore the issue of conflicts of interest, the problem of objectivity and the role of credibility when the family keeps control. One of the consequences is a revolving door between government and industry so ensuring that government embraces corporate ideas. The second page looks at a number of government appointments to show what happens and the consequences. The third page looks at the tensions that can arise in government departments as they struggle to keep a lid on what is really happening when they are threatened by whistle blowers. The culture of the organisation changes. Companies can have the same problems when they are threatened by whistleblowers. This page goes on to examine the difficulties in getting information and the strategies used to keep it under wraps.
This is not a criticism of individuals, but an analysis of how the social forces generated in a culturopathy play out and their impact in aged care.
For example, when the National Aged Care Alliance (NACA) was formed to work with government in making aged care policy, members had to agree not to criticise any policy that the provider dominated majority had decided on. NACA wanted concensus and not criticism. Of the three large senior organisations in Australia, two chose to resign rather than be muzzled. They have been unable to participate in policy development. The third group which has fewer members decided to stay. It has benefited by receiving grants and funding to undertake work for government.
It has become the de facto spokesperson for government and often industry, making important announcements. In doing so, they create the impression that the programs (eg. global trade agreements involving aged care services) are supported by the majority of seniors. This has meant that the larger seniors groups have been excluded and only the one that was prepared to become one of the family has been part of the decision making group. The community's voice has been divided and conquered. The seniors group that filled the role of seniors representative for both government and NACA, and whose CEO became the public face of NACA and government policy, has been promoted to the public as the voice of Australian seniors. It has prospered. The groups critical of aged care policy have struggled.
The hub: The proposed Community Aged Care Hub creates a context, which invites the caring professions and the community, to take charge of the situation, collect accurate information and then generate paradigms that will enable changes to be made in the sector. Appropriate policies will follow.
When the market proposes innovations they will not work through NACA and government but through their local community hubs and any proposals will require the community's support. As the community and its representatives on the hub becomes more educated, they would heed the 18th century father of economic theory, Adam Smith's warning that any proposal "which comes from this order ... ought never to be adopted, till after having been long and carefully examined ... with the most suspicious attention". We might like to add politicisns to the order we need to be suspicious of. Under our currrent system success for politicians comes from selling illusions which they are then trapped by.
The primary characteristic of a well developed civil society is prudence and its most important role is to critically examine any proposal that anyone makes. Society needs to focus the common sense built on their diverse experiences and a knowledge of history on any new idea. Proposals need to be tested before being generalised. Innovation is the way forward but it must stand up to scrutiny I hope that the proposal to make the community the driving force in aged care using something like the proposed hub will be examined in this way.
The perspective I am using is not prescriptive. It does not tell us how to fund and run aged care. What it does do is show the problems in what we are doing now and suggest an organisational structure that will both allow soundly based policies to develop and be in a position to protect the sector from a similar ideological onslaught in the future. It does not seek to exclude governments but to involve them. It would provide a pool of knowledgeable and effective people whose prime interest was the welfare to the community. They would be better suited to hold positions of responsibility than the family.
The proposed hub would aim to bring together members from all of the seniors groups as well as many others from the community. They would gain knowledge, expertise and influence so forming a broadly based community group - a structure within civil society that can represent and act for civil society in regard to aged care issues. It would not replace others representing seniors but invite their contributions to the care of the frail elderly and to improving their quality of life.
Learn more: To explore this issue further view Keeping it all in the family (Web page not live yet)
Markets and culturopathy
In this section I round off my arguments. I look critically at the marketplace we now have and then contrast that with the arguments made by Robert Kuttner and Joseph Cavalleri, showing how this and the proposed hub fit in with what they are talking about. I look more closely at the role that individuals can play in restructuring civil society and organising it to be more effective. The focus is on doing that in aged care.
The other issue that needs attention is the top-down authoratative method of making decisions. It needs to be balanced with a more democratic and restraining bottom/up decision process. One size does not fit all.
The reasons for claiming that we are looking down the barrel of a culturopathy are summarised. A final page looks at some experiences and suggestions showing how a more educated (as contrasted with trained) society might protect us and how the proposed hub would put the community in a position to address culturopathy when it develops.
The first Markets and culturopathy page summarises these matters. It has links to four more detailed pages with views and examples.
Learn more: Markets and culturopathy (Web page not live yet)
A cooperative system
Cooperation is key: What is proposed is a cooperative joint venture of the community, the health professions, government and providers of care. They would all be focused on securing the best possible outcome for residents and the community with the available resources. When more resources are needed they would engage the wider community to secure these.
A market that serves society: Markets are successful to the extent that they serve society and clearly we expect an aged care market to do this. Their involvement in a joint project where the hub would be the customer would ensure this. The hub's activities, including their collection of data, would support them in their role.
Backup protection: The oversight and regulatory role and powers vested in the community hub would work in harmony with the providers. It should not be intrusive and should support and help them. But they are essential in a vulnerable market like this. They will ensure that it stays on track and that deviations that might threaten care will be quickly stopped.
Confidence: Confidence and trust will be restored. Anyone who questions what is happening can look at the information the community has collected to check up and argue their point of view. There would be no room for the wildly conflicting assertions that are such a blight on the aged care system we have in Australia today. There would be a forum where ideas coming from the coal face or the board room can be evaluated and change driven with consensus.
In conclusion: the thrust of these pages
On these web pages I have set the provision of aged care within something much wider. I have set it:
- within a group of vulnerable markets that are failing,
- within a group of societal institutions (the churches) and core commercial entities (the banks) that have failed us, and
- within a wider society that holds beliefs and within which we are all building and leading lives. As we do so, we define who we are and decide what we are here for.
Looking at a human failing: Within all of this I am looking at a human weakness or failing. Building our lives and our societies is so important to us, the things we believe in so valuable to us, that we have great difficulty in challenging failures. We make every effort to ignore and look past unpalatable truths. We rationalise and when that fails angrily reject criticism. When all else fails, we try to cover up our failings. Our emotions are blunted and we can harm others. We do this individually, as groups and even as nations and none of us are immune.
We can see examples of this in individuals who have a mission or find meaning in activities that are built on ideas that are illusionary. Without them their lives would become meaningless and they fight to defend themselves. This is how we humans behave.
There are the churches that, under pressure to promote and protect their religion, shielded paedophiles and looked past the consequences for their victims. This is how those who are there to meet our spiritual and personal needs can betray us,
The financial advisers in banks did the same to build their careers. The banks looked past this and then tried to cover it up. I saw the same thing in the giant Wall Street Financial Institutions, and in the US health and aged care systems. In all of these, the sectors were there to look after us and advise us but instead exploited our vulnerability.
We have political examples in fascism and apartheid where vast misery resulted. Communism became a belief system for a large part of the world, millions died in Russia and China. It extends to everything that we humans do.
Looking at ourselves and our aged care system: I have examined our current political system and its globalised counterpart in multiple countries using the insights gained from looking at it this way. We are all at risk and we should be constantly alert to this.
In all of these situations individuals were responding to the environment and the situation in which they found themselves, building their lives in the best way that they knew how. We need to look critically at these environments and see if we can change them to make them work better.
In dealing with aged care, I have tried to grapple with something very complex in us and in our societies that makes us behave in these ways. I explore aged care and come to the conclusion that our politicians, our providers and most of our community are human too. Their unwillingness to confront what is happening in aged care, as well as the flaws in their proposals for change, is a manifestation of this problem.
I have spent a lot of time, effort and some complexity seeking to explain something I think throws a useful light on many issues but the one I concentrate on is aged care.
I do this in order to promote something very simple that if embraced and acted on with enthusiasm by our community, would be a first step in addressing this problem in aged care.
Aged care is only a part of a much bigger problem in our society, the hollowing out and weakening of civil society. Government, markets and civil society can be seen as the three pillars on which western capitalist societies depend and why they have been successful in serving mankind. Civil society is the holder of our values and our norms of acceptable behaviour. It holds the other two to account and ensures that they serve society.
Over the last 25 years, markets have successfully canabalised the other two sectors and their thinking has come to dominate both politics and society. Civil society has been disengaged and "hollowed out" losing its knowledge, its power, its confidence in itself and so its control of the world we live in. It is no longer able to exert its critical role in western societies where it has been replaced by the market.
Aged care is only one example where the consequences are readily apparent but it is a good place to start doing something about it. The proposed aged care community hub is one of a few early attempts to re-engage citizens and rebuild civil society.
I apologise if it is complex and I have been long winded, but some of the ideas are difficult to explain and I have done my best.
Finally, can I remind you there are many different ways of seeing and understanding things. I have briefly commented on some 21st century ideas that are interesting on the Aged Care Crisis web site in Part 4 - Developments in Social thought. You may like to look at them and follow some of those links. Some are congruent with what I have said, others are not.