No one can predict who will end up in a nursing home and so which family's inheritance will be appropriated. Instead of setting up a fair go insurance style system like Medicare where people, who through no fault of their own needed expensive aged care, the Howard government tapped into family savings in order to support its free market solutions. But after an outcry, accommodation bonds were charged only for low care residents. After years of inquiries and a lot of promotion, the community were finally persuaded to go along with this. Currently everyone in a nursing home pays either bonds or large fees.
Liberal policy makers have been philosophically opposed to Medicare and wanted to abolish it, but this was so popular that Howard would not have won the election in 1996 if he had not agreed to support it. But this is something that neither he nor his successor as liberal prime minister Abbott would have countenanced in aged care. The ideology dictated that everything be structured as a free market.
Different perspectives
If we look at the material that is publicly available, we find three very different perspectives.
- There are those who are strongly motivated and have identified with the ideals of person centred care and are doing their best and do so within and believing in the system or do so in spite of the system. They write about their efforts and promote them.
- Those who believe in the system and see the negative publicity as the problem because it undermines trust. They are responding by putting out positive material to counter this. That is typical “market-think” and not the way to address the problem.
- Those who realise that there are problems and think that regulating and punishing offenders will fix the problem. That is a “responsive” way of thinking. They are reluctant to challenge the status quo.
- Those who have examined the system and see it as fundamentally flawed and a failed market. They want to see changes that will change the system and make it work so that we don’t have to rely on regulation.
The first two groups feel threatened by the criticism and do not understand that it is not directed at them, nor is it directed at the true believers as individuals. There are issues that we cannot continue to ignore and I address these on this web page.
Why 'Aged Care in the dark'?
I have called this section 'Aged Care in the dark" and there are four forms of darkness that we need to consider.
- When we have no accurate information on which to base our decisions and Australia does not collect any. In this situation, we fall back onto our everyday beliefs and I will show that they can be very unreliable.
- The second form of blindness is ideological blindness. This is the blindness we get when we believe in something and this belief is very important to us. In this situation we simply do not see what is in front of us. We ignore or discount evidence, logic and common sense so that we can continue to believe. Instead of recognising the problems in the system we see the criticisms themselves and the people who make them as the problem.
- The third form of blindness is the blindness of order. We humans like to have a highly ordered world and are uncomfortable in the disordered one we live in. We try to structure what we do by developing processes and regulations that encompass every eventuality. The problem here is that we live in a very complex world and our order and processes never fit adequately so this becomes inflexible, not adaptable and people fall through the cracks.
This results in blindness because having to follow complex process means that what we tend to becomes routinised, almost a habit - task focused rather than person focused. When we work in this way we tend not to think about what we are doing. Imagination and reflection are suspended. We need imagination and reflection to enter into the lives of others and experience their pain and suffering. We lose empathy and do not see the suffering that others experience and that we may be causing. It is dehumanising. - The final form of blindness occurs in high pressure situations. These operate in a similar way. We simply do not have the time to imagine and reflect so we do not see the plight of others. If we do see, we put it off but never get back to it. I have already dealt with this in the earlier marketplace sections. An excessive drive for efficiency at the bedside results in task focused activities and this has the same effect. We fail to see and enter into the life of the other.
It is not possible to provide humanitarian services effectively in a system where we cannot enter into the life of the other. We are unable to empathise, and to provide the critically important interaction, emotional support and social context that they require to build lives in the situation in which they find themselves. This is essential to enable them to “realise their condition” and make the most of their lives.
Our current aged care policies and practices fail in all of these ways and as a consequence it is not fit for purpose. It has become "all show and no go". The "show" is for those who need to believe. The "no go" is for the residents and for the staff who do look and reflect and who struggle to provide real care in spite of the system.
The web pages summarised in the sliders below and linked to from them look at these issues in depth.
Tip: Click to expand (+) or collapse (-) content on this page
Policy made in the dark
The first linked page explores the development of policy in aged care by looking at the recent Living Longer Living Better reforms. It comments on the absence of local data, the failure to consider international data as well as some of the dynamics within the current system.
It then moves on to look at the way that free market ideology has turned paradigms developed within the sector over many many years and the knowledge of the past on its head. Ideas developed from outside were imposed.
It looks at the processes used by the government, processes restrained by the need to avoid confronting deeply held ideological beliefs in markets and in managerial processes. Strangely the outcome of this was the very opposite of the 21st century principles that leading members of the bureaucracy had been advocating for some years.
These principles are the same principles that underpin the proposed Aged Care Community Hub. It is suggested that the proposed hub is the best and most efficient way of undoing the harm done, abandoning failed 20th century processes and introducing the 21st century to aged care.
Learn more: Policy in the dark
Consequences of marketplace thinking
The web page linked to from this slider examines the consequences of the new patterns of thinking and the social processes and policies that followed. It looks how the focus on money rather than on good care, which had once been provided, led to the exploitation of any loopholes that could be found in the system and the exploitation of the vulnerable people they were supposed to care for.
The linked page use some examples in health and aged care in the USA that illustrate the thinking that has developed in the marketplace and the consequences of that particularly well. They illustrate the way that believing in what you want to believe rather than looking at what you are doing not only harms people but slips easily into outright fraud.
In Australia the funding system has been repeatedly exploited by providers. Governments have been forced to stop funding provided for complex and difficult cases because very soon vast amounts of extra funding were claimed. Recipients of home care have been charged exorbitant administration or case management fees. It is ironical that the government that is attacking the industry for rorting the system is not in a credible position as it has similarly been "maximising" the loopholes in legislation controlling party political donations.
The linked web page looks at the problems inherent in a complex hierarchical bureaucracy and its dehumanising effect. It uses the complex funding system to illustrate the adverse results of this approach to aged care.
Excessive and dedicated government regulation can be a dead hand strangling the system and even destroying worthwhile community projects. There has been a lot written about this in the UK
Learn more: Consequences of marketplace thinking
Further consequences of a dominant for-profit marketplace
This page revisits some of the issues for the threatened not-for-profits and then looks at the impact that consolidation and the centralised organisation that accompanies it has on society, including the hollowing out of local knowledge, local expertise and local involvement of citizens in aged care. This applies whether the consolidation is by for-profit, mutual, or not-for-profit organisations. Related to this is the break up of social stability that the current focus on markets above society is causing. The most vulnerable including the aged are most likely to suffer.
For profit providers are there for the money and not for the community. When there is a downturn in the sector for any reason they will vacate it and abandon the residents. If they are unable to do so and must hang on their responsibility will be to maintain the profits of investors above the care of their residents. If they don’t do that someone else (eg. turnaround specialist) will buy them and do just that.
Once the sector is dominated by for-profits they are in a position to dictate to government. The government dare not let the large companies go under and leave them responsible for the residents. Having sold off their own nursing homes the government does not have the resources to step in. Companies can go on a spending spree and build up large debts knowing that if they are threatened by bankruptcy, the government will have no choice but to increase funding to rescue them.
Learn more: Further consequences of a dominant for-profit marketplace
Analysing in greater depth
It should be obvious that what we have in aged care is a consequence of the way that those responsible for designing the system and those “stakeholders” lobbying government think.
On this web site I am concentrating on how people conceptualise situations and how this is translated into real world outcomes. This is a good time to introduce some broad ideas about society, and look at how we, as humans, develop our ideas and why all too often we get it hopelessly wrong.
The linked web page addresses issues like civil society and the public good in order to underline the context within which aged care operates. It then explores our essential nature and the forces that impact on us as we struggle to make sense of our world and what happens when we succeed in doing that. It looks at how the ideas that now dominate aged care developed.
Learn more: Analysing in greater depth
The Community Aged Care Hub
And so we come at the end of all this to look at a possible way out of what is best described as a mess - to the proposed hub. This is a segment of civil society drawn from the diverse members of our community, inclusive of and representing the real life situation and diverse lives of old people, talking to them and working with them, their families and their carers in search of common ethical and humanitarian objectives.
It is intended to create the sort of contexts that confront belief and bring the breadth of experience and ingenuity of the community to the endeavour. It ticks all of the constructivist boxes and more. It is focussed on the common good and not on anyones personal interests.
It has the power to force true believers to come to the table and engage. This is the essential step in confronting ideology and the words used to clothe it in legitimacy. By doing so we release those who are trapped within it from its tight embrace and they too can express their humanity.
Clearly nothing works without a grasp of the world we live in and some sort of order and structure. A flexible and adaptable structure not rooted in absolute truth, located close to and closely connected to the real world of the aged must work better than one imposed from elsewhere - a distant hierarchical one generated elsewhere and where decisions are made in distant places. This is not to exclude the broad view from outside because outsiders can often see more clearly but to set their ideas against real world practical contexts.
When we bring diversity as well as the full breadth of our many societal attributes and our knowledge of our past to the table near the bedside we can imagine what we would like to see there then look at the probabilities which we know will keep changing. We can start working our way carefully towards what we would like.
It would be very different to the impersonal centrally planned and structured system that we have now. The providers would continue to provide but the pressures would be removed and they can rejoin the human race!
On the web page Aged Care Roadmap in the Introduction section there is a table comparing the system we currently have and this roadmap for the future with the sort of system the Community Aged Care Hub that we are proposing is intended to create.