The first failures in care
The first major scandal was at the Riverside Nursing Home and occurred in 2000 only three years after the new system was introduced and 18 months after all staffing requirements were removed. A year later, there were problems at the Ritz and Yagoona nursing homes in NSW. Over the years since then there have been recurrent scandals. Elderly women have been raped. Nurses have amused themselves by mocking residents and playing demeaning games on them. There are examples of neglect.
Deaths due to neglect or injury have been covered up and families kept in the dark. They have only come to light when courageous junior staff have reported instances to police or when the matter has been referred to the coroner. Food in many facilities is extremely poor.
The Riverside scandal as well as a number of reports of poor care created a lot of angst in the community. But many people still remembered the debate and the predictions made in 1997. We were assured that these were exceptions in a good system. The government were still vulnerable and these early signs of failure were followed by a number of inquiries. Those I looked at did not acknowledge that they were a response to the Riverside scandal.
A good place to start our discussion is by looking at what government did to address the evidence that the system introduced in 1997 was not working because it is a good illustration of what has happened ever since.
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Inquiry after Inquiry after inquiry
Following the Riverside scandal we saw the start of a long cycle of reviews of aged care federally and in the states. These were carried out by parliaments, by government organisations and by commercially contracted consultants. Many were undoubtedly stimulated by the intense and ongoing unhappiness in the community and the adverse media coverage. Much of the focus was on money, but there were strong criticisms of the accreditation process and of the complaints system. Many complained about staffing and care and there have been calls to collect more data about the standards of care. None of this has had any significant impact.
I have argued for a long time that there were a number of elephants (or should we call them sacred cows) in the room at all of these inquiries. All participants turned their eyes away when they were mentioned so that they did not see them. The first of these was the introduction of a free market into a sector serving vulnerable people who did not have the power to protect themselves. The second was that both the accreditation process and complaints system were fatally flawed in concept, philosophy and design. Neither were fit for purpose for what was expected of them within a free market system.
While there has been much tinkering, the fundamental beliefs and patterns of thinking that underpinned all this were never challenged and when they were raised they were ignored. While there may have been some benefits when changes were made they were very limited. They can be seen as plugging leaks in a rusty bucket.
These core beliefs are still the basis for the Living Longer Living Better "reforms" that we are once again being subjected to. I argue that the persistence of these core beliefs will compromise the outcomes. While there might be some improvement, they will not realise their full potential.
It is interesting that, although there have been frequent calls to collect objective data about standards of care, there have been no attempts to do so. It is not clear whether this was because the industry and their influential supporters were too powerful, whether the changes needed to collect reliable data would have meant the downgrading of accreditation - a pillar of the system - or whether data collection was seen as 'regulating' which was anathema for true believers in free markets.
A succession of inquiries: In 2010 I examined and wrote about 32 of these inquiries starting with those in 1997. The core problems were spelled out in the early reviews but were ignored.
The Gregory Report that preceded the 1997 legislation offered two alternatives. The government selected the free market option even though the Gregory report had indicated that with this system “neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit”.
The majority report of the 1997 Senate committee review of the proposed legislation was concerned that “ensuring quality of care in nursing homes will be a major challenge for the new Aged Care Standards Agency” and “there is a strong perception among consumers and their representatives that 'a significant focus of the Agency will be the needs of service providers' to the detriment of consumer interests”. The minority report by government members attacked the opposition but did not confront the issues. The government ignored the recommendations to better protect consumers. It probably needed common sense and not hindsight to realise that this would happen.
Following the Riverside scandal, we had the Aged Care Amendment bill inquiry in November 2000 which treated this as an isolated exception. An inquiry into the labour force in 2001 revealed a 20% drop in the number of nurses working in aged care. A comprehensive senate committee inquiry into nursing in 2002 examined the impact the shortage of nurses was having. It drew 988 submissions. Its majority report described what was happening and the evidence for this. The minority government members report attacked the decision to call the inquiry but did not dispute the evidence. The government continued to make exaggerated claims about the care provided and few if any changes were made.
A succession of subsequent reviews all went the same way. I wrote these web pages before the 2010 Productivity Commission review in the hope that it would be different and I urged people to make a submission. Like its predecessors, it turned out to be a damp squib. In spite of all the hype around it and the Living Longer Living Better reforms that followed it was, and still is, more of the same. The big bull elephants still stand guard and inside the sacred cows are fat and healthy.
- Oh no! - not another aged care inquiry Corporate Medicine web site June 2010 (My examination of 32 inquiries)
- Conclusion: A time to change all this.: What the reviews reveal about the 1997-2010 era Corporate Medicine web site. (my summary and conclusions)
The review that was buried
The Riverside scandal occurred in Victoria. The Victorian labour party were critical of the federal and state liberal government’s failed policy of privatising public hospitals, some of which it reversed. It also criticised its aged care policy including the inadequacy of federal regulation when compared with the standard of state regulation before the Kennet government handed regulation to the Commonwealth in 1995.
A very interesting review was commissioned by the labour government in Victoria in July 2000 only 3 months after the Riverside scandal. We only learned of this recently when a google search for something else found the consultation paper on the web site of a not-for-profit aged care provider. It is interesting that we could find no trace of this inquiry or any documents relating to it on the Victorian governments web site. The site seems to have been been purged of seditious material!
We have no idea what happened to this inquiry but the consultation paper clearly sets out what the state labour government was considering. What we do know is that none of it happened. Its what Aged Care Crisis and many many others have been calling for over the years, but neither party has been in the least bit interested in listening.
Labor recognises that one of the best ways of ensuring that Victorians receive the highest quality in residential care is to ensure that they are fully informed about the operational capacity of their facility.
- Victorians deserve the right to know about the number of staff employed by their facility as well as the qualifications of the staff.
- Labor will restore State regulations for aged care facilities in Victoria, including patient/nurse ratios.
- Labor will require nursing home providers to better inform residents and their families of the numbers and qualifications of staff.
Source: High Care Residential Aged Care Facilities in Victoria Consultation Paper July 2000 Department of Human Services Victoria
The paper refers to five other aged care initiatives ongoing at that time, all directed to addressing issues in aged care. It acknowledged that state governments power to regulate Commonwealth funded aged care in the state was limited and that may be why it failed or was abandoned. It described the extent of the financial and staffing accountability that had been abolished by the federal government in 1997. It expressed a willingness to be involved in handling and resolving complaints but indicated “concerns about the effectiveness and timeliness of the external mechanism and the enforceability of any determinations made by a Complaints Resolution Committee.” The paper listed 12 significant issues of concern in the aged care system that stakeholders had raised, but which only the Commonwealth could address.
The paper indicated:
- “an important characteristic of residential aged care is the inherent structural power imbalance”,
- doubts about the “capacity of families to make rational and informed decisions”,
- “- - residents (and their representatives) fear retaliation or retribution”,
- “have little bargaining power either at the point of entry to, or within, a system” and that
- “Even a regulated system will only work equitably where both consumer and provider are able to transact on an equal level with similar bargaining powers.”
That certainly sounded like a lot of common sense . A really good place to start but then it seems to have died.
As you read through the remainder of this section and particularly when you read what is being said by those at the coalface of care in 2016, ask yourself if anything has changed at all. Have any of these matters been addressed or responded to. Then ask yourself why, with so much effort and so many inquiries, the situation seems to have gone from bad to worse.
Then consider what Aged Care Crisis is proposing. These are all among the issues that the proposed Community Aged Care Hub is designed to address. It is intended to address them in such away that there can be no more fudging or hiding what is happening.
Advice that was ignored
At roughly the same time in 2001 The Australian Health Institute at the University of Sydney commissioned a paper by Hal Kendig and Stephen Duckett. The paper was titled Australian directions in aged care: the generation of policies for generations of older people.
The paper gives a useful review of the development of the aged care system during each political period starting with Robert Menzies. It focuses primarily on finance and demographics. It also looks at the problems particularly the difficulties in access for many. They authors noted that “the interface between the various service systems is disjointed” and so poorly coordinated. This was partly due to different funding sources. The paper refers to the intense debate about aged care in the 1998 election and about the policies in 2000 before the next election. It acknowledges the difficulty in addressing the interests of the elderly that are created by “the strength of entrenched interest groups, power relations and resource constraints”. It emphasises the importance of a consultative approach.
They seem to have recognised the difficulties in the centrally managed and operated system. While they did not see the community as central to this, their main recommendation was to devolve funding and management of aged care services to local regions so that the funding could be flexibly managed locally. What interested me was the benefits they saw in this.
Regional fund pooling
It is proposed that all Commonwealth and State funds for aged care services be pooled into a single fund to be managed at regional level. The funds pool would incorporate residential aged care, Home and Community Care and community aged care packages, and relevant State-funded community health activities.
One of the advantages of this approach is that the supply of care can be tailored to local circumstances, such as those in rural and remote areas, and that additional supply can be carefully gauged to meet priority gaps in provision.
Another advantage is that the funder/s of services are close to the providers of care and this will enhance coordination and accountability, including quality of care. A single point or consistent points of assessment can allocate resources (and case manage where necessary) on the basis of comparative need. All of these approaches should increase the appropriateness, and hence cost-effectiveness, of provision.
Priority for drawings from the pool should be determined locally - - - , and managers of the pool should have the flexibility to reallocate funds across portfolios. - - - they would have autonomy over the number and mix of residential services including Community Aged Care Packages.
The main point is that the shape and mix of services will be determined more by people who directly observe and experience the consequences. Regional Boards will also be well placed to advocate for older people and their needs - - - .
Ideally, the pools would develop their own dynamics to ensure local responsiveness and flexibility.
Our first major recommendation is for regional funds pooling that would allow local communities to make judgments about where the gaps are to ensure that the services better meet consumer needs.
Information is the key to ensuring more transparency in government and to identifying ways to increase the appropriateness, cost-effectiveness and equity of aged care services and related policies. Understanding the many influences on older people’s health and wellbeing will point the way towards priority policy areas where there are opportunities to improve ageing experiences.
Source: Australian directions in aged care: the generation of policies for generations of older people. Australian Health Policy Institute Commissioned Paper Series 2001
Aged Care Crisis has also identified almost all of these factors and we have the same objectives. Like the Community Aged Care Hub that Aged Care Crisis are suggesting the authors recommend a central advisory board including government supporting the regions. In our view this is essential, particularly in the early stages when community has not yet gained confidence. Without it community groups can be drawn into the corporate culture and lose their independent point of view.
The authors accurately describe the problems that have plagued the centrally controlled aged care system since 1997 - managerialism. I write elsewhere about the hollowing out of civil society, why it occurred and the consequences. Our proposal directly confronts this problem.
Policy development has increasingly become the preserve of bureaucracies and government, with interest groups having only occasional successes in shifting bureaucratic or government opinion.
Bureaucracies and bureaucrats are not, of course, disinterested players. They have their own interests which unfortunately can occasionally be about bureaucratic comfort or aggrandisement rather than the interests of consumers or taxpayers. Dysfunctional bureaucracies lead to overly bureaucratic rules, overly rigid eligibility criteria, cost- and blame-shifting between Commonwealth and State governments and to policy silos that militate against integrated solutions to need. Policy advocates outside bureaucracies would be able to cite aged care policy examples of all of these problems.
They give considerable attention to the need for evidence in policy development and of research and data gathering for this. They end their recommendation with a quote from geriatrician Dr Sidney Sax:
‘In reworking our social obligations to each other and assessing what entitlements society is prepared to offer the older generation, consultation with and involvement of the affected parties have become essential parts of the process of policy development.
In this report we are looking at another missed opportunity, but no one was listening. No one wanted to know. We would very probably have have had a very different system if we had gone this way in 2001.
The proposed Community Aged Care Hub - similarities and differences: This report accurately identifies many of the problems that persist in our aged care system today. Their proposal has many similarities to what we have suggested at Aged Care Crisis. It would deal with the same problems in similar ways.
In our view giving the community itself control and an even larger role and much more power would be a superior way of achieving these objectives in the free market system that we have developed since then. We should not underestimate the power imbalance that has developed and grown since 2001. If the proposed hub is given the powers that we have suggested it be given then I believe it would be even more effective. The weakness of the authors proposal is that it does not specifically empower the community. But the real importance of the community having a direct and powerful role in providing community services has only recently been appreciated and currently government policy has not really embraced it. Power is something that you should hardly ever need to use, but when you do you must have it.
The proposed hub will need the support of government and the professions in order to develop the skills it needs to be effective and work with providers on an equal footing and have “equal bargaining powers”.