The more eyes, different eyes, we know how to bring to bear on one and the same matter, that much more complete will our “concept” of this matter, our “objectivity” be.
Source: Friedrich Nietzsche’s critique of truth in his 1887 book On the Genealogy of Morality, Quoted by Alexis Papazoglou in The post-truth era of Trump is just what Nietzsche predicted. The Conversation 15 Dec 2016
Too often reasoned debate comes down to a conflict between different points of view - an either/or situation where we must choose one or the other. It becomes a reflection of the power and rhetoric of one or other side. Someone wins an election in order to impose their biases and we call it democracy. Rather than looking at the strengths and weaknesses of each point of view when making decisions it seems that we are doomed to live within the limits of our own biases.
Our difficulty is in escaping from our nature and instead developing our capacity to be reflective - a giant step for mankind! This section looks at the way our biases take us down blind alleys and expose us to harm. It explores the reasons why we, as an evolving social species, do this and why we find it so difficult to reflect on alternative points of view and include them in our thinking.
The argument is that insight comes from standing back and looking at events from multiple different points of view and that wisdom is the capacity to evaluate these different insights in order to identify what is significant and use that when reaching conclusions and making decisions. We need to be able to bring large amounts of information together and see the patterns and relationships within them as well as the differences and conflicts. We need to find ways of understanding the forces and processes behind events. It requires some effort and thought but most of us are capable of doing some of that if we make the effort. Wikipedia provides a quick way of looking up words and ideas.
The people who study it: It is always a good idea to look at what those who study the sector we are interested in have to say about what is happening. In academia there are multiple disciplines and multiple perspectives that each throw a different light on what is happening and so reveal more. Our issue and the focus of this web site is aged care and the strong perception that it is not working for many who need care as well as for those who provide that care. The particular concern are the patterns of thinking that are being applied by society to aged care, the cultural conflicts that have arisen in the sector and the real consequences of this. Much of this has been studied but few are listening.
In this section I am going to look at some of the ways academics have examined and studied aged care. They throw light on the problems in a system that is not working as well as we expect it to.
Society: But first we need to turn to society itself because aged care is part of larger society and it is the larger society that has restructured aged care. To understand the forces at play we need to look at the history as they developed and then at what is currently happening to society. What are those who study and criticise our society saying about it. Are there lessons from the past? Are there lessons for aged care?
Aged care has been radically changed by turning it into a market using neoliberal belief systems. It is now configured and considered in terms of small government, free markets, economic rationalism, individual autonomy and responsibility, microeconomic reform, incentivisation, managerialism and regulatory capitalism. The study of aged care as a part of society is the province of the discipline of sociology and it is the impacts of these ideas on society and on aged care that sociologists discuss and study.
Contents: This page starts by looking briefly at the story of markets and how academic economists embraced what we now call neoliberalism and sold those ideas to the leaders of our world. After 47 years neoliberalism is showing signs of stress, has come under pressure and is being strongly criticised. Many suggest that it is time to move on but no one is clear where we should go. A linked page explores these issues.
The next section looks briefly at the discipline of sociology and some theoretical concepts. It moves on to the work that different groups of sociologists have done in aged care. Their work either bumps into or directly examines the consequences of free markets for aged care as well as the neoliberal agenda. Linked pages explore their work.
Between 1996 and 2008 I wrote a large number of web pages about dysfunction in health and aged care in the USA and Australia on a web site. I revisit that work broadly through some more recent social theory which throws considerably more light on it particularly the reasons why regulation has failed so badly.
There is information about some of the social theory of the mid 20th century. This picks out some useful concepts that should be helpful in building systems that work for society and its citizens.
Finally, I look at the nature vs nurture debate, first at the way incentives and disincentives influence people in the marketplace and secondly how this impacts on the genes we inherit - genes that predispose us to behave badly there.
Tip: Click to expand (+) or collapse (-) content on this page
Markets and Society
Human societies have been built on trade. Markets have been the foundation from which wealth has been created. It has been the engine of social development becoming ever more sophisticated. While markets have been the engine that makes the sort of society we have possible they are not society itself. Society has always needed much more than trade or markets could provide. It has been supported by a multitude of other organisations whose object was to serve groups of citizens or wider society in many different ways. Because the prime focus has not been the accumulation of wealth or personal advancement we describe them as not-for-profit or nonprofit.
Markets – capitalism - neoliberalism and the post-truth era
Traders to guilds to capitalism
On the first linked page I have briefly traced economic history from the earliest tradesmen to the organisation of markets through guilds in the middle ages. These were supplanted by the growth of capitalism in the 18th century when the first theorists analysed and wrote about it in depth. Many of their careful assessments and warnings are still relevant. The social benefits that they saw from the balance of forces between markets on the one hand and customers and civil society on the other led to the arguments that markets could serve society. They warned of the risks for society if it did not keep the market under control.
The Industrial revolution
The social benefits were not realised when the industrial revolution in the late 18th and 19th centuries destroyed the agrarian feudal society. Industrialists dominated and their belief in free markets ignored the constraints that theory required. Government supported them. This created widespread inequality. Citizens including children were ruthlessly exploited. Those who were left out were sent to the colonies or assigned to prisons and poorhouses.
Discontent and rebellion in the early 19th century was crushed. Workers eventually mobilised and consolidated again. This led to the formation of unions during the late 19th century. The collective power they exerted improved the lot of workers. The “second industrial revolution” during the latter part of the 19th and the early 20th centuries was more equitable than before. The boom and bust instability of free markets led to the Great Depression of the 1930s and the Second World War.
Keynesian economics developed during the great depression. Reconstruction after the war was based on more stable regulated markets. We saw the rise of socialism and the development of more stable welfare states.
Re-emergence of free markets and the rise of neoliberalism
The stable regulated market did not generate the same wealth. Free market ideology resurfaced among economists in the 1970s and became policy in Western countries in the 1980s. Regulations that constrained the excesses of markets were lifted. Free market capitalism appropriated globalisation as its own as it developed. A global civil society has not developed in the same way. As in the industrial revolution the benefits have been reflected in the greater wealth of nations. This has been at the cost of greater inequity in society and the re-emergence of poverty amidst wealth. Financial instability has once again become a major problem.
The central problem throughout this history has been trying to find a balance between the wealth generated by capitalist markets on the one hand and its risks, lack of equity and propensity to divide society and to exploit the less fortunate to benefit the fortunate on the other.
The political ideology that has driven the resurgence of free markets is called neoliberalism by its critics. One of its founders in 1970 declared that social responsibility was socialist and therefore evil. The only responsibility was to make a profit for shareholders. That heritage has influenced policy. But neoliberal theories have extended far beyond markets. They have radically changed society and the way people think. The welfare state has been restructured to reflect its beliefs. Its thinking has been applied to every facet of our society including government itself – infused into every vein. Nonprofits have been reorganised and restructured in the same way as companies and markets. All of society is expected to conform and function in the same way. While we boast about diversity and individual freedom both are constrained by the requirement to conform to this model.
The driving ideas of neoliberalism have been called micro-economic reform (competition and efficiency) and managerialism (top/down structured control). Both major political parties have adopted these principles and there has been no significant political opposition. Important contributing processes have been incentivisation and marketing, the latter driven by public relations specialists. The new economy focuses on and is sustained by consumerism. These concepts are explored on the linked web page.
The sustainability of free markets is being challenged by the threat of global warning, by the unsustainable utilisation of limited resources and by the destruction of our environment that their utilisation entails. An increasingly large number of thinking and reflective individuals are challenging the quality of life that it gives. Technology is meeting its promise of freeing us from the tyranny of work leaving less work for citizens to do. Without any planning for this, unemployment is growing. It is growing in a social system that does not provide a context in which the unemployed can live and develop meaningful activities and identities. Instead they are stigmatised.
The promises made by the neoliberals are not coming true for most citizens and political claims too often defy credibility. The public have become increasingly disillusioned and distrustful of politicians. The argument is that neoliberals have taken civilisation down a blind alley and they have no answer to the crises that are rushing at us except more of the same - more rhetoric, more claims to excellence, and more attacks on their critics. Politicians' identities are tied to their beliefs and they cannot find a way forward that is not more of the same. – a state called paradigm paralysis.
The post-truth era
The year 2016 has been a watershed year in which citizens have stopped believing in politicians and in fact everything they have been told and previously accepted. They are faced by a social system that is no longer working for them and by politicians who have not met their promises and have no alternative future to offer them. Citizens have become distrustful of evidence and those who provide it. Even academia and its research findings are impacted. Sciences’ status and objectivity is compromised. Our social fabric is undermined.
But humans require meanings and some sort of order in their thinking. Some develop their own appealing ideas and gather followers. You get a splintering of groups and then splintering within these groups. This is a dangerous situation because society becomes vulnerable to charismatic leaders who appeal to emotion in order to promote narrowly focused but appealing unsafe ideas and policies that are ultimately harmful. A disillusioned society readily coalesces around these ideas and society goes off at a tangent. This is not the first time this has happened. Similar situations were seen in Germany in the 1930s, in South Africa after the collapse of colonialism and possibly in Russia and China as well.
The Trump phenomenon, Brexit and the recent political developments in Australia can be seen as manifestations of this situation. Our inability to formulate a sensible alternative way out of the maze that led us into this cul-de-sac carries real risks.
Wise men: Wise men from the past have reflected on similar situations and have left us with sensible advice.
Is it not better to remain in suspense than to entangle yourself in the many errors that the human fancy has produced? Is it not better to suspend your convictions than to get mixed up in these seditious and quarrelsome divisions?
Source: 16th Century French philosopher Michel de Montaigne commenting about turmoil in France. Quoted in Advertising is driving social media-fuelled fake news and it is here to stay by David Glance The Conversation 9 November 2916
It is interesting that, as 20th and early 21st century ideologies have created global problems and wars in which millions of deaths occurred, the words wise and wisdom have largely disappeared from our discourses. In my opinion that is what we have lost and what is needed. We seldom hear wise words and to find them we usually have to look to the past.
Wise men have been through similar crises and have told us how best to deal with situations like this and bring back wisdom. I will return to that near the end of this section.
The not-for-profit (nonprofit) sector
Throughout history mankind has formed groups of people who worked together in order to help one another or further the aims of the group or of society at large. Collectively they formed the backbone of what we have come to call civil society. These groups have become more diverse and increasingly complex. It is increasingly difficult to classify and study them. On the linked page I provide links to this history and background for those who want to explore this. Then I look more closely at those nonprofits providing human services.
Our focus here is on the not-for-profits that serve our human needs and weaknesses. Many of these originated as charitable organisations developed by religions to serve their communities.
Of interest for aged care is the extent to which neoliberal ideas have been imposed on and been accepted by this nonprofit sector and the consequences for care. They have been forced to become competitors in unrestrained markets where their reasons for existence are challenged. If they don't conform they struggle to survive. As they and an increasing number of citizens become part of the market and adopt its modes of thinking and operation, civil society, as an effective and constraining force, has withered.
Later in this section I will comment on theories of power that illuminate this process. Elsewhere on this web site I have described the way neoliberal ideas have been adopted by not-for-profit aged care providers and some of the consequences of that.
The argument and the challenge
The argument on this page and on this web site is that developments and pressures in society, together with our propensity to seize on simple all-encompassing truths has repeatedly led us to ignore the complexity of life and the alternate perspectives that explain it better. We have been vulnerable to simple self-serving ideas that enable us to escape complexity and so act decisively if unwisely in the world.
The disastrous 20th century and the crises of the early 21st are testimony to our weakness. In the 21st we are faced by a society that abhors complexity and too often converses in tweets and sound-grabs. The argument is that the neoliberal agenda is a simplistic concept based on a single perspective from only one sector of our society. It harms other sectors. It has had a major impact on our societies as a whole; some positive but others negative.
The challenge for us now is to look at it critically but at the same time avoid grabbing on to more proffered truths and emotive but simplistic ideas. Instead we should accept the complexity of the world we live in, the social animals that we are and the societies we create. We need to look at all this from multiple points of view so that we see all sides of an issue.
The question is whether we as a species are sufficiently developed to build a society that embraces complexity and uses multiple insights (as contrasted with a single belief) to put us in control of our destiny? This is an enormous challenge because it means challenging our very nature – the patterns and responses that we have developed as our species evolved.
It means confronting uncertainty and coping with it. There are ways of approaching this but no one is really talking about them. Our average intelligence has been increasing by 10% each generation but instead of using it to challenge and reflect we have used it to justify beliefs rather than challenge them. Instead of focusing on improving or developing a better system we strive for personal achievement within the system we have and become alienated when that cannot be achieved.
The linked page
The linked page expands on this section. It adds to the historical material and gives links to articles about it. It then explores neoliberalism in greater depth and looks at the criticisms that have and are being made including the predictions that it is on the way out. But, without a sensible alternative, neoliberalism is possibly a long way from its last gasp! We need a more sober approach, one that ensures that we look carefully at what we are doing before we move ahead and do not throw out the baby with the bathwater. The linked page looks in more detail at the claims that we have entered a post-truth era. It looks at what is being said about that and its risks. It explores possible implications.
There is also a short look at the history and extent of the not-for-profit sector with links for those wanting to explore further. The focus on the nonprofit sector moves to human services, principally health and aged care. The page finishes with a short overview of the commercialisation and corporatisation of health and aged care. There is more on other pages.
Link to Markets and society
Sociological research and aged care
There are many definitions of the discipline of sociology - most simply “the study of the development, structure, and functioning of human society”. In a long article covering the many areas sociology focuses on Wikipedia is more detailed describing it as “the study of social behaviour or society, including its origins, development, organisation, networks, and institutions. It is a social science that uses various methods of empirical investigation and critical analysis to develop a body of knowledge about social order, disorder, and change”. Wikipedia has also written a digital book “Introduction to Sociology”. I don’t have sufficient knowledge to comment on either.
From our purposes we can look at this more broadly as Macrosociology and Microsociology.
Macrosociology “emphasizes the analysis of social systems and populations on a large scale, at the level of social structure, and often at a necessarily high level of theoretical abstraction”. There are a number of different sub-disciplines but they all look at society more generally rather than at individuals.
Microsociology addresses “the nature of everyday human social interactions and agency on a small scale: face to face. Microsociology is based on interpretative analysis rather than statistical or empirical observation, and shares close association with the philosophy of phenomenology”. It too has a number of sub-disciplines.
Additional sub-disciplines have developed that bridge the gap between these two approaches and some studies and analyses use both. Each of these perspectives and the subdivisions within them throws a different light on the subject investigated.
Foucault: A number of more recent investigations of vulnerable sectors including aged care use the ideas developed by the late 20th century French philosopher Michel Foucault. These have become increasingly important in understanding what is happening in health and aged care.
Foucault's theories explore “the relationship between power and knowledge, and how they are used as a form of social control through societal institutions”. Several studies draw on his analysis of the way power influences the language and content of discourse – the way people interact and communicate as well as the pattern of ideas within which communication occurs.
Others draw on his concept of “governmentality” which he uses in a very broad sense not only to include how governments and organisations control citizens but how people control one another and how we control ourselves and our own actions. The concept focuses on the way we identify with the ideas in the discourse and make them our own.
Power based on knowledge allows those with power to set the limits of acceptable discourse and so limit what is discussed and accepted by individuals and groups as truth. Studies in aged care usually focus on the microsociology side of this, the way staff experience and respond to power in the context in which they find themselves – the way they are controlled by discourse.
Our interest in studying aged care is the concept of governmentality, the shaping of the way we think and act - of who we become. It can be studied from government policy as revealed in documents down through businesses and nursing homes to the day to day lives of the nurses as they discuss and provide care. They readily incorporate the government's principles and ideas into their everyday lives and make them a part of who they are - it 'enters into their souls'. A failure to do so puts them at odds with the system.
Important in this is the concept of discourse and by this Foucault means more than the way people engage whether in writing, on social media or in day to day conversation. It refers to discussions that are variously described as 'organized in a regular and systematic way', 'share the same formative system' and 'rendered in a particular conceptual form'. Discourse is also frequently constrained by what is excluded, what it is not acceptable to say or to consider and what is not credible. Researchers look at the discourses that are used to implement neoliberal policies and the way they conflict with nurses' professional discourses.
Example: The vulnerability of the elderly and their families, the predatory nature of markets and their lack of social responsibility all sit poorly in the neoliberal discourse of markets, consumers and choice. We don't see them in the discourses of government and marketplace documents or speeches. In ordinary language we talk about 'elephants in the room" when we refer to the things that are not acceptable in the discourse. They belong to another discourse that is discounted and not used.
Governmentality is mediated through discourse and this is how society achieves its objectives. As explained on the page 'Conflicting cultures' we struggle to deal with conflicting discourses and experience discomfort when faced by this. We frequently employ psychological coping strategies to escape the need to confront the conflict.
The third concept is power and it is the power to control discourse that matters, controlling the way things are conceived and discussed, the formative systems or conceptual form. Equally, if not more important, is the power to decide what is not part of the discourse, what is permissible and what is not credible. The main source of this power is knowledge or rather the control of knowledge and the control of knowledge creation. It is also not difficult to see power in hierarchical organisations, in wealth, in success, in the marketplace, in leadership, in credibility, in dominant and confidant personalities etc. There is social power of some sort in all relationships.
Much of this has been known and researched separately for a long time. In the 1970s I was interested in some of this. In 1996 in the introduction to a paper I wrote analysing how vast numbers of US nurses and "doctors were induced to place the interests of the company ahead of their duty to patients”, I wrote about what Foucault calls 'discourse and power'. I explained how protagonists “set the parameters within which discussion will take place so that it is framed within the ideas being promoted” and how difficult it was for critics to “articulate their discomfort in regard to the concepts being promoted”. I indicated that “they have credibility and can control group perceptions”. I was experiencing this myself at the time because a US expert had been invited to help my hospital restructure in a neoliberal direction. As chairman of the medical staff association at the time I was struggling to argue against it even as many colleagues were persuaded - and I was well informed.
What Foucault has done is to bring all this together in a way that makes our understanding of how our society operates much more meaningful and understandable. As Foucault indicates these closely connected concepts are integral to the structure of society and enable it to act in a coordinated way. We can also understand how ideology can take control of our lives and cause us to do things that are not in our or our society's best interests.
Discourse and aged care
Discourse and culture: The patterns of thinking, the discourses we use and the ideas that give them legitimacy are clearly critical to understanding the differences between cultures and subcultures. Maintaining the discourses on which cultures depend is critical to their survival. Cultural conflict can be seen as a clash of contradictory discourses. The health and success of cultures can be seen to be related to the extent to which the discourses and core beliefs on which they are based are synchronous with the real world and its complexity - or escape into illusion.
Neoliberal discourse: In analysing we can identify two discourses. The neoliberal discourse and the ideas on which it is based are discussed in the first part of this page and on the linked page "Markets and Society". We can talk about a free market culture.
Discourse of care: While they do not use Foucault's concepts or talk about discourse the section below headed "Professor Fine and associate" as well as the linked page "The Nature of care" can be seen to be exploring and refining the discourse of care and in doing so defining a culture of care, which they describe. They write about the impact that the neoliberal discourse has for the culture (and so discourse) of care.
Analysis: The section "Nurses use of their time" and the linked page 'Nurses under pressure" uses time and the way it is used to explore the impact of neoliberal thinking and management on nurses thinking, the way they understand their role and the way they reorganise their time to cope with this. It examines the way they struggle to cope with the way this conflicts with their professional culture and discourses (part of the discourse of care). The consequences are measured by looking at 'missed care'. Attempts are made to counter this by educational endeavours to build empathy a key component of the discourse of care. Several of the research reports use Foucault's concepts.
In the section "Foucault: A reinterpretation" and the linked page I re-examine studies that I did of health and aged care in the USA and Australia during the 1990s and early 2000's using Foucault's insights. Looking back Foucault's ideas simplify and a shed new light on what I found. The spread of the neoliberal discourse and its consequences is readily tracked from academic economists to Wall Street and then into politics, health, aged care and into regulation in both countries. I describe how the discourse spread to Australia, was checked and confronted in health care, but prospered in aged care and 'captured' its regulatory system.
In research articles used on these web pages.
- Kathleen Lynch gives a good description of the compelling nature of power and discourse in her description of the impact of New Managerialism on education indicating that “it involves the management of identity as a modality of control that includes ‘managing the insides’ of workers, in terms of their hopes, fear and expectations of success in the work organization”.
- Julie Toffoli gives a good summary of Foucault’s theories in her 2011 thesis ‘Nursing Hours’ or ‘Nursing’ Hours. She did a detailed study in a hospital.
- In her 2006 nursing thesis Behind Closed Doors Anita Bellis describes the role of Foucault’s concept of discourse impacting on nurses in aged care.
Other articles about Foucault's work give more depth.
- Foucault, Governmentality, and Critique by Thomas Lemke presented to Rethinking Marxism Conference, University of Amherst 2000 (This is an early analysis of governmentality and its use in critically examining neoliberalism)
- Governmentality: Notes on the Thought of Michel Foucault Bal Sokhi-Bulley School of Law, Queen’s University Belfast Critical Legal Thinking 2 Dec 2014 (A more recent legal look at this with a legal slant)
- Foucault: power is everywhere on Powercube web site Participation, Power and Social Change team, Institute of Development Studies, University of Sussex, UK (A good description of the Foucault’s concept that ‘power is everywhere’, diffused and embodied in discourse, knowledge and ‘regimes of truth’, what "makes us what we are", and "constitutes agents rather than being deployed by them").
A personal interest in these disciplines
My background in the turbulent 20th century led me to an early interest in the ideologies that empowered people to do terrible things, killing the people that the ideologists blamed for their misfortunes as well as millions of others. I puzzled about how they could bring themselves to this. By the 1970s I was closely involved with several different groups in a dysfunctional society. They each had conflicting but from their perspective clearly logical views. Each saw what was happening very differently. It was particularly interesting to see the way the discourse was narrowed and controlled so that each point of view was protected from others who might challenge it.
This led me to do some university level courses in social sciences and read around these issues. At this time microsociology was a relatively new but growing discipline. I found it interesting and very helpful.
That background was very useful to me as a whistle blower during the 1990s and since then in acting to protect our health and aged system from large multinationals with a history of exploiting and misusing those they were responsible for.
I have not had time to study social theory in any depth since the 1970s so this journey back into social theory is a quick update for me! Foucault's theories have developed since that time. They throw a new light and add to my understanding of what happed in the 1970s as well as in assessing developments in health and aged care since the 1980s.
The Corporate Medicine web site I wrote between 1996 and about 2008 was informed by my earlier studies. It is essentially a record of what founders, executives, managers, critics, documents and press reports in the USA and Australia revealed about the companies in health and aged care and how this explained their conduct. Although not intentionally written as such it is essentially an analysis of the cultures revealed through the many eyes that looked at them – an account informed by my earlier interest in social theory.
This Inside Aged Care web site adopts a similar approach and can be seen the same way. It is particularly interesting to look back at my findings in the 1990s through the additional lens of Foucault’s ideas of discourse, power and governmentality.
Tokens and tokenism
I did not see “tokens and tokenism” as important concepts in the material I read about Foucault. He seemed to be primarily interested in how discourse, power and governmentality interacted in any society and was not looking specifically at dysfunctional ideology.
My interest has been in ideas that people believe in that don’t work and at how people are able to justify what they do in the face of logic and reason. Tokenism plays a critical part in this.
Tokenism is variously defined as “the practice of making only a perfunctory or symbolic effort to do a particular thing” or “formal or superficial compliance with a law, requirement, convention, etc”. It is often applied to the tokenistic employment of women or racially different individuals in order to show compliance with expectations.
In this sense I argue that the primary but unstated role of regulation within the neoliberal state is to protect the neoliberal discourse and in doing so shield the government and the marketplace from embarrassment. Effective regulation would challenge the neoliberal discourse, by exposing the validity of complaints and revealing failures in care. To maintain the validity of the discourse and control over knowledge regulation must be a “perfunctory or symbolic effort” - tokenistic.
There is nothing new in this. In the US corporate health sector Peer Review and Quality Assurance committees have been in place and management has boasted about them. In practice they seldom if ever met and were stacked with team players so were tokenistic. In the corporate health care sector peer review was used to sanction and get rid of those who were not team players and who were critical of the care being provided in the hospital. Quality Assurances committees have been used to support and counter criticisms of prominent team players in the corporate system.
In addition I often use 'tokenism' more broadly to include the use of positively and emotionally loaded words that refer to something that needs to be there but which is either not there or is deeply flawed. The rhetoric around assertively used words like ‘quality’ or ‘excellent care’ often refer to something which is not there. The discourse requires that they be there for the discourse to be valid. The words become tokens for something that should be there but is not.
Ritualism: Another concept ritualism has received a large amount of attention in aged care and particularly in regulation. This essentially refers to the development of rituals and processes which become the focus of attention rather than the events or failures in care that the processes are intended to address. The rituals and processes become tokens for the care that should be there or for regulations that should expose failure. As a consequence care is omitted and regulation fails.
How tokenism works in discourse
Dysfunctional ideologies or culturopathies either ignore or distort the real world. They have to manage the discordance that results in order to maintain their legitimacy and hide the consequences of what they do from consciousness. Tokens are used primarily by believers to deceive themselves and shield themselves from what they don't want to know. They can continue to believe and support the discourse with conviction. That conviction is affirmed for them in the assertive way in which the tokens are promoted in the discourse as unchallengeable fact. They use their power to exclude and discount any arguments or ideas that challenge the tokens in the discourse.
We can relate this to the section I wrote about Willful Blindness and Bad Faith on the web page Culturopathy: A for-profit example. The discussion there related to authenticity and inauthenticity and to the not always easy to grasp idea of Bad Faith used earlier in the 20th century by another French philosopher Jean Paul Sartre. He explained how we escape authenticity in order to be the person we need to be by lying to ourselves.
To maintain the integrity of the discourse in the examples i use and the situations I describe believers must abandon authenticity. To do so and remain genuine they must deceive themselves. Tokens provide a ready tool that enables them to do so.
I met with a manager of a large and successful hospital operated by one of the largest US hospital corporations. I had complained about a Quality Assurance report supporting the care provided by prominent doctors. I received an hour’s assertive lecture boasting in glowing terms about the company’s commitment to Quality Assurance and this hospitals quality assurance process. There was no doubt of his sincerity and his belief and no way in which I could argue against him.
I later discovered that this was the first time the Quality Assurance Committee had met, and that Quality Assurance Committees in this company’s hospitals seldom met. When doctors in one hospital pressed for the committee to meet because very profitable doctors that the company supported were doing unnecessary major surgery, this was blocked by management. Within their discourse the doctors who were unhappy were jealous of success and were being malicious.
In this company Quality Assurance was ‘tokenistic’, but for them, including these managers, the tokens were real and represented something they were proud of and which justified their existence – enabling them to discredit their critics and reject evidence and arguments without confronting them. This is what happened to me when I criticised.
We can also see that the manager I met was deceiving himself because he knew this committee had only met once – an example of bad faith and inauthenticity. A similar process of tokenism and bad faith was used by the managers who called doctors who criticised a colleague doing unnecessary operations 'jealous'. The word 'Jealousy' became a token for something that was not there. Tokenism allows people to believe anything they need to use to justify and defend themselves. This is a fundamental and common coping strategy for those of us who have to be inauthentic in order to be successful within the prevailing dominant discourse. Culturopathic systems depend on it for survival. It should not surprise us that it is occurring within the conflicted accreditation process.
Sociological research in aged care
Two groups of sociologists: I have looked predominantly at the work associated with two groups. The first is from the Department of Sociology at Macquarie University in Sydney under the leadership of professor Michael Fine. This work is predominantly within a Macrosociological perspective. The second are associated with the departments of medicine and nursing at the universities of Flinders and Adelaide in South Australia. Their research is mainly into the plight of nursing staff and their difficulties. Many are authored or co-authored by Professor Eileen Willis or Dr Julie Henderson. There are related studies that provide insight and also studies from elsewhere that are of similar pattern.
On the web page Aged care roadmap in the introduction to the Inside Aged Care web site I described the government’s aged care roadmap and suggested that its lofty objectives could not be met because of the structure of the services planned in the roadmap. Professor Fine’s papers explore this issue by examining the nature of care and then explain why it will be so difficult to provide the sort of care that is required using the planned market based structure.
The Adelaide groups explain what the consequences of these policies have been for staff in hospitals and aged care.
I have made short summaries of a number of articles obtained from web sites including Researchgate. It is impossible to summarise the depth and the insights of this material in order to do it justice. I have selected those things that were relevant to my arguments. I hope that this representation is fair.
Reviewing previous work: In the 1990s and early 2000s I wrote extensively about health and aged care failures in the USA and Australia and the failure of regulation to detect or constrain any of this. In this section I gain a greater insight into this by re-examining what happened using Foucaults insights. What they reveal about the regulatory process is particularly interesting.
Regulating aged care: There is the work of criminologists like John Braithwaite who wrote abour regulatory capitalism and who studied the regulation of aged care.
Nature versus Nurture: The practice of incentivisation has played an important role in driving socially unacceptable practices and this is explained. The presence and possible role played by the expression of genes for bad behaviour is examined when those with them are placed in contexts where their expression is encouraged.
Professor Michael Fine, Dr Bob Davidson and others
Professor Fine's papers closely examine the history and the complex nature of the caring process in considerable depth and from multiple points of view. They can be seen as looking at what is needed to provide the service that the studies indicate is required. This is then set against the marketisation of aged care showing the difficulties in meeting the actual needs of care in this way.
Professor Fine and associates' articles
The problem finally comes down to how care that should be based on intimate reciprocal personal relationships can be provided in a system that requires it to be commodified and traded competitively in a sector where the consumer is dependent, vulnerable and without information. Fine is particularly concerned about the situation in which aged care workers find themselves because their working conditions impact on their capacity to build the sort of relationships on which good care depends.
Dr Davidson has studies community services and writes about these. He too looks at the neoliberal agenda, the sort of market it creates and how it can be controlled. He looks at the risks, where and how for-profits might be controlled to protect the system. He writes about the likely survival of nonprofits and is more optimistic than I am.
As Fine indicates “the richness of academic discussion on the topic of aged care stands in contrast to its limited use in policy”.
As an introduction I have tried to pick out some points from multiple papers that I hope will give the flavour of the material. The link to a page containing short summaries of the individual articles is at the end of this slider
The points below are not in strict chronological order. I have simply tried to give a feeling for the nature of a large volume of work covering several representative papers and I have not read all they have written.
A selection of points made in these articles
Professor Fine and associates papers included a warning in 1992 that privatisation was an inadequate framework for care and a 1995 study that showed that care in the community provided by family was preferred by the elderly and that support services were only supplementary but very important when needed. By 1999 an increasingly user funded system had been introduced and problems in this were identified.
A historical review indicated that feminism moved women carers out of the home into work starting in the 1960s. At the same time the elderly were moved into institutions where task focused care destroyed their individuality and their identities. In the 1990s dire predictions about the rising costs of aged care saw the elderly moved back to the community where in the absence of women they were expected to pay for their care so shifting responsibility for funding away from government. But this was an inequitable system as care cannot be treated as a commodity.
Later papers explore the nature of caring as a process in transition. They examine the sort of relationships needed for good care. The papers discuss dependency, interdependence and the balance of power in caring relationships. Care is positioned as a chain of obligations based on qualities of reciprocal dependence linking members of a community.
In 2012 papers explore the complexity of care and the contrasting ideas about the giving and receiving of care. Examples include whether it is a labour of love or a commodified product, moral value or economic value, rights and justice in relation to emotion, empathy and physical contact, and 'caring about' versus 'caring for'. These ideas all impacted on these complex, reciprocal and mutually supportive relationships.
He is particularly concerned with care in the community and considers formal care to be important in complementing and sustaining these carers during times of increased pressure. It was a shared responsibility. As a relationship care shapes the lives of both those who receive and who give it and formal care is critically important in supporting and enabling this relationship.
Later papers are particularly concerned by the casualised, insecure and exploited workforce and the difficulties they have in forming caring relationships. The aged have moved from being patients to citizens and clients, and now to consumers and this also impacts on relationships.
Neoliberal policy is criticised because it “re-expresses individualisation as a form of ‘consumer choice’ and does not recognise the full person”. The idea of individualism is often abused. It is reducted to market-based consumer choice and behind this lie the hidden exploitative approach to care workers and unpaid care-givers.
In other papers he writes about ageism and the way the elderly are conceived and understood. Neoliberal attitudes constitute the aged as a looming economic problem and as a poor investment. The opportunities for meaningful social engagement and personal development that longer retirement offers, described as a self-realisation of a type that work seldom provides, are ignored and are not attainable with simplistic solutions like privatisation.
The neoliberal approach ignores the emotional component of care turning it into an employer/employee relationship so that it becomes “less emotive” and simply “cold, hard, support”. Social and economic pressures influence the way that care is conceptualised and provided, and constrain further development of the concept. Care is seen in terms of a personal service (ie not a relationship), as a cost issue in financing care, and as a global economic development. Policy creates large divisions between managerial staff and a larger insecure workforce that is treated as disposable, particularly globalised staff (eg. on visas). This intrudes into intimate relationships and personal lives.
In 2015 the papers return to the nature of care and of dependency by exploring the complexities of power within caring relationships and the relationship between power, dependence and dominance. Dominance is the illegitimate use of power. He looks at whether responsibility lies with the local group or family or with everyone. He suggests that caring and being cared for is a part of everyone's life and all of us are responsible. He suggests that what is required is a public ethic of care so that we all have a responsibility for both the worker and the charge and that this should be a central concern for justice. The neoliberal belief in rational adults takes no account that all of us are dependent at various times, in fact we are interdependent on one another.
In another paper he writes about the various cultures of care. He classifies these on the basis of 'caring for' and 'caring about', being warm or cold, and traditional or modern. What varies between them is the value placed on care. Professional cultures have been appropriated by management cultures. This can be seen as 'high touch' conflicting with 'hi-tech' cultures. Care cultures are a “creative and living production” responding to change. They cannot be reduced to financial incentives and labour market opportunities as they are based on values and ideals linked closely to personal identity.
As each aspect of care is explored and teased out in these papers its realisation in practice comes up against the inappropriateness of the market driven neoliberal agenda.
In his writings Fine and his colleagues draw on a vast amount of work done by others and in a concluding remark he indicates that the richness of academic discussion on the topic of aged care stands in contrast to its limited use in policy.
Bob Davidson, Fine's colleague writes about for-profit and non-profit providers and about relationships with government and about different types of markets and their implementation in human services. He is particularly interested in community care. He also writes about choice and control in market based services in the disability sector.
Other authors: I have included brief outlines of a few similar articles from other Australian universities. The first looks at isolation and the potential negative impact of neoliberal policy on the isolated. The second is a comparison of staffing between for-profits and nonprofits about which I have some reservations. A study of nurses looks at the importance of reciprocal relationships of various types in aged care, particularly in job satisfaction. They comment on the extent to which reciprocal relationships are inhibited by "time-starved ‘industrialized’ work environments". There is a link to a blog critical of competition policy in health care. A paper looks at empathy and the way the pressures of daily life inibit it for doctors and nurses.
To appreciate the full meaning and depth of these articles you may need to read the original but I hope I have been able to catch some of this in the short summaries I have made on the linked web page.
For a summary of each paper link to The Nature of Care
Most of the articles in the next section come from the Flinders and Adelaide universities in South Australia. They largely focus on the experiences and conduct of nurses as they are subjected to neoliberal management techniques, and the consequences of this for the care provided. A central theme of this work is time, its cost, its significance and its centrality in management’s approach to nursing. The articles examine the way nurses are persuaded to manage their time in the interests of the business and the impact of this on the care provided.
Many of the studies are done in hospitals and some in the community but their relevance for aged care is clear. Several use Foucault’s ideas as the basis for their analysis.
Nurses use of their time
Professor Eileen Willis is author or coauthor of many of the papers. Her first paper is a study of time going back into the 12th century when the belief in purgatory flourished. Sinners were persuaded to frantically employ their time (a treadmill) in order to reduce the time they would spend and the severity of their suffering in purgatory. They did this to atone for their sins before they were eligible to ascend into heaven. She traces the pressures generated at this time through the development of capitalism and into the neoliberal period when nurses are persuaded to enter managerial purgatory. She follows this with a second paper about time describing her 6 year study in a hospital as neoliberal management strategies were introduced. She uses the words dismal failure, alienated workers and waste of public funds and a descent into chaos to describe what happened.
Two papers explore the natures of neoliberal policy and its introduction first into the community mental health care system and the second in the way it resulted in fragmentation of mental health services for the older patients. Both had adverse outcomes.
An important doctoral thesis for the University of Sydney explores the impact of neoliberal policies on nurses in a hospital using Foucault’s theoretical perspective. It traces management policies about nursing time from government documents, through hospital policy documents, to nursing documents and into the day to day conversation of the nurses. It shows how nurses ultimately internalise these ideas and come to see their role as serving the hospital and its business objectives as much as their role in caring although 'excellent care' was what they were selling. They assumed responsibility for managing their increasingly restricted time in order to provide ‘5 star care’ in spite of the difficulty in doing so in the available time. They identified with what they were doing, were satisfied and proud of it - the business' concerns became their own.
While limited resources have meant that missed care or rationing has always been a problem in nursing. But missed care in order to generate a larger profit for distant investors is something new. There has been an increase in missed care since the introduction of newer forms of neoliberal management. Several papers looked at the incidence of missed care, the sort of care that was missed and the reasons nurses gave for their inability to supply the care they wanted to give. Four of these studies were in hospitals and two in nursing homes.
A study performed for the nursing union to determine the skill levels and numbers of staff needed to provide safe care found that these closely approximated those long recommended in the USA. They were nearly double those reported in Australia. A comparison of aged care staffing levels between Australia and the USA collected from international and local sources by Aged Care Crisis showed that Australian residents get on average less than half the amount of care from registered and enrolled nurses and overall less that one hour of nursing care per day than in the USA. US data show that levels of staffing and the incidence of failures in care closely follows the pressures for profit when provider types are compared. Very limited Australian data suggests a similar trend when sanctions and accreditation failures are examined.
Other articles describe attempts to foster empathy by bringing emotional experiences and training into education. There are short papers about immigrant nurses, about male nurses and about the shortfall in non-cancer palliative care.
To read short summaries of these papers link to Nurses under pressure
Reviewing US and Australian data: Although it is not necessary to use Foucault’s theories to grasp what happened in health and aged care in the USA and Australia during the years 1980 through to 2008 when I studied it, or the company Tenet/NME that I used as an example of a culturopathy in the Cultural perspectives section, his ideas do bring what I have written in the past together. They throw some additional light on this. Importantly it provides a new and deeper insight into why regulation was so ineffective in the USA and Australia and why it remains ineffective. It is well worth looking at those events and issues in a different way.
Foucault: A reinterpretation
Different terminology: On the web pages I wrote analysing health and aged care in the USA and Australia between 1996 and 2011, I used the words ‘pattern of ideas’ or ‘paradigm’ rather than Foucault’s ‘discourse’ which included this but focuses also on the processes of communicating them. I talk of ‘power’ and ‘credibility’ whereas he ties power more closely to having knowledge and controlling it. I speak of ‘internalisation’ and ‘identity’ whereas his term ‘governmentality’ includes that but goes much further to focus on the way we control one another as well as ourselves, a process that extends from government to individuals. So we are talking about the same things but with a different emphasis.
Reinterpreting: I wrote many web pages between 1996 and 2011 and on the linked page I revisit and reinterpret that material using Foucault’s concepts to bring it all together and to look particularly closely at the failures in regulation where Foucault’s ideas provide much more insight. This is important because John Braithwaite, who has studied the USA and Australia has been critical of the US regulatory system by looking at the process itself. While he commented on the way regulation had been captured in the USA and Australia. I am not sure that he appreciated just how much of a problem this was. He has not understood it in this way. I have not yet read all of his work on this.
Regulation: Foucault’s concepts provide an additional explanation of regulatory failure in addition to Briathwaite’s. By placing it within the wider context of discourse we get a very different view.
The other reason for failure is that the US system relied heavily on the combination of large amounts of information used by effective well informed customers urged to make choices. That had limited success as too many residents and their families have not been effective well informed customers capable of, or been motivated to, make choices in a sector where they still think they can trust those who care for them.
Outline of the linked page
The growth and spread of neoliberal discourse: The page describes the discourse that developed in Wall Street during the 1980s into the 1990s using Citigroup as an example and showing how these companies took control of the way knowledge was controlled and understood. Their interpretation of the nature of the market led to their own multiple frauds and the frauds of those they advised. This is examined by looking at the leaders, at the discourse (what was said or written) and at the conduct of the companies and their staff.
The web pages then use the concepts of power and governmentality to follow the embedding of this discourse through Wall Street financial advisers to executives and managers in health and aged care companies and then on to the staff and even the patients in the sectors. They show how the power of doctors was broken and how they were recruited to the discourse. The close links with politics and government are described and the nexus of politicians and the market based on this shared discourse. Finally, there is the globalization of the discourse and its adoption in Australia.
A counter-discourse: There was a second highly critical but fragmented community based discourse which took a contrary view and recognised problems. It was made up of academics who had studied the sector as well as staff and families whose adverse experiences led them to look more critically at what was happening. While lacking in power they have been able to inconvenience and sometimes make small changes. This was done in the USA by using the courts, and in both countries by publicity and public anger.
Neoliberal response: The neoliberal discourse is constantly threatened by the real world of human suffering and emotion on which it is imposed - and must confront and discredit this counter-discourse. It depends on a never ending stream of rhetoric. It has developed subsidiary discourse built around tokens that seeks to discredit its critics and is supported by exaggerated claims to the rigour of regulation. Regulation and its tokenistic vigour are vitally important in legitimising the discourse. When it fails it threatens the discourse.
The impact in health and aged care: The passage of the discourse into the leadership and management of a hospital company and an aged care company are used to examine the discourse in these two sectors. The page describes the manner in which the discourse led doctors and nurses working with these companies to cooperate in defrauding insurers and government by exploiting the vulnerability of their patients and in many instances causing them extensive harm.
By seizing control of the interpretation of knowledge and distorting it these companies became very powerful in the Foucaultian sense. Staff patients and community accepted that what they were giving and getting was good care when it was nothing of the sort. Regulators were blinded by this and accepted or ignored what was happening even though it should have been obvious. In each instance it was isolated outsiders who saw what was happening and took action to expose the fraud and the harm done. The power driving this discourse was so strong that for believers even criminal convictions failed to dent it, and companies claiming to have reformed continued to behave in the same way and to re-offend.
In Australia: The progress of the discourse in Australia influenced marketplace and political thought and so the decisions made in health and aged care. The strong influence of US ‘authorities’ on the discourse is described. Several health and aged care multinationals were recruited and welcomed into Australia. They received strong political and market support in spite of extensive information about their unsavoury and fraudulent international conduct.
Regulation: The neoliberal interpretation of knowledge and the discourse in regard to regulation has been largely negative about any sort of regulation. One of the strongest neoliberal exponents and an authority on aged care expressed the underlying messages. He indicated that government should butt out and leave it to the market. The belief was that the market was self-regulating and that any interference impeded this process. The same aged care authority said “The quality of health care suffers because of governmental support and regulation. The system takes away incentives to improve”.
Regulatory capitalism: So governments in both countries have policies that advocate and claim to be doing less regulation. At the same time, they have been forced to regulate more because of public concern and failures in the system. So while claiming and perhaps believing that they are reducing regulation both countries have seen a massive growth in regulatory activities of various sorts. Many academics including Braithwaite consider that 'neoliberal' is the wrong name to describe the last 40 odd years. They describe this era as ‘regulatory capitalism’ instead. So within the neoliberal discourse there is a fundamental logical conflict that must be ignored - an example of bad faith. Regulation is bad yet they have been forced into extensive regulation. It is hardly surprising that it becomes tokenistic and fails.
Controlling regulation: Regulatory vigour and independent data both potentially threaten the neoliberal agenda and it is hardly surprising that believers will ensure that it is kept in safe hands. The regulatory system has become critically important in responding to any criticism of the marketplace in aged care.
In setting up regulatory processes, credible industry and marketplace participants become advisers, consultants and committee members. While some regulation is kept in house, other is delegated to ‘independent’ organisations who are appointed and funded by government so are under pressure to be compliant. Regulation can be contracted to competitive private companies. There are multiple Quality programs run by industry and by big corporations themselves. They are at risk of becoming tokenistic, as in the examples I give, or of being used to trap potential whistle blowers.
The regulatory system is ultimately controlled and run by government and marketplace. It is constrained by the dominant discourse and those who manage it must conform to that discourse if they are to be credible and acceptable. While it may not be intentional the regulatory system becomes a mechanism for protecting and supporting the industry and its stakeholders rather than the vulnerable community they claim to defend. It does not work for them.
In his 2007 book 'Regulating Aged Care' Braithwaite descibed his recent study of the regulatory process in Australia. He considered that it had been ‘captured’ by the market and in essence was serving them in keeping adverse information out of the newspapers. He described the way assessors who recommended standards be failed were overruled by their superiors. Others lost motivation and no longer failed standards. He warned of the consequences of what was happening for residents. What Foucault’s concepts reveal is that the regulatory system in both countries was created by the neoliberal discourse and this discourse is deeply embedded in the DNA of those who manage it and so in its staff. A discourse looks after itself and does not turn on itself. It has never been independent. Braithwaite's observations are readily explained and the problem seems to be worse than Braithwaite thought.
Regulation protecting industry
When the system is under threat the defense has been to boast of the rigour and effectiveness of the regulations in order to belittle those who complain and to undermine the credibility of their critics.
Example: A web site created in ‘late 2016’, sometime after the ‘Inside Aged Care’ web site went live is named ‘Inside Ageing’. It professes to be ‘an independent publication’ but to also be ‘backed by some of the most influential leaders in aged care’. It places itself within the discourse.
Inside Ageing posted a page responding to articles in the Bundaberg Mail and ABC News, a change.org petition with 35,000 signatures and a Chanel 10 TV segment that alleged major failures in care in a for-profit facility in Bundaberg. The Queensland Nursing Union supported the claims of poor staffing.
The article denigrated the efforts of the families who complained and used the accreditation process to prop up the defense rather than question accreditations utility as regulator. It suggested that this was all essentially a beat up by the nursing unions to support their campaign for registered nurses in all nursing homes.
- - , FPCompanyQ, has had to defend itself against the negative reports despite having passed all recent inspections by the Aged Care Quality Agency.
FPCompanyQ director Mxxxx Oxxxx told the ABC the been audited twice by the independent Australian Aged Care Quality Agency in the past two months, following concerns raised by Mrs Mxxxxxx and another resident’s wife. - - - - both found they were delivering quality standards of resident care.
Source: FPCompanyQ MEDIA COVERAGE COINCIDES WITH LATEST ANMF CAMPAIGN Inside Ageing 6 Apr 2017
As revealed in the section Widely Contrasting Views and particularly the page How Aged care is perceived the infallibility of the accreditation process has been used to confront criticism and promote the corporate agenda since at least the early 2000s.
Implications: The analysis shows that regulation has been created, governed and managed within the neoliberal discourse. Regulation's primary but unstated function has become and remains the protection of the neoliberal state and the discourse on which it is based. Effective regulation exposes failure and threatens the neoliberal discourse. The accreditation and complaint processes have become critically important tokens within the neoliberal aged care discourse. Without them the discourse would lose support and dissolve.
The Foucault message is clear. Whoever controls the discourse can and generally does ensure that the paradigms (patterns of ideas) that are used there are their own. It is unlikely that any conclusions made or actions taken will challenge the thinking or the activities of those who have power. This is not deliberate, evil or consciously self-serving. It is how they think and what they see as appropriate - how normal humans behave. This is why meeting within contexts where those you criticises can control the discourse can undermine your position.
The lesson for those seeking to counter ideology or culturopathy, is to gather together, forge logical arguments based on evidence. With a solid knowledge base that exposes the ideology one which you control, you will have the power to force your patterns of thinking into the centre of the discourse and make change. But be careful to acknowledge what is good and do not create another ideology that is also harmful. The lesson of history is that this often happens.
To explore these issues Link to Re-interpretation using Foucault
Some consider that neoliberalism is a misnomer because although neoliberalism has been the driving ideology its practical adverse consequence has been the burgeoning of regulation to constrain its excesses. The term Regulatory Capitalism better describes the era particularly for those whose interest is in crime and in regulation. Many have written about it.
Regulatory Capitalism in aged care
Regulatory Capitalism and Civil Society
The primary criticism is that regulatory capitalism is a reflection of the weakness of the neoliberal position and of the way it has failed society. As Eva Cox commented in her Boyer lectures in a Truly Civil Society citizens are involved at all levels in the affairs of their communities and the country. Issues are identified early and addressed in dialogue. They are resolved using the pressures within social discourse. As a consequence, formal regulation should rest lightly and be seldom used. It should not be onerous.
Regulatory Capitalism is a reflection – a marker – of the extent to which civil society has been undermined, hollowed out and disempowered by neoliberalism and its managerial processes. It has become a regulatory monster that a sensible society would be better without.
The neoliberals are correct in that we should have less of this sort of regulation but to do so we need a system that needs less regulation than the neoliberal one – a very different more distributive, less onerous type of regulation in a more sensible society. We need a system that includes regulation but a system in which both its organisation and its regulation capitalises on society’s strengths rather than weakening it and then capitalising on those weaknesses in both politics and in the marketplace.
A contradictory system
Regulatory Capitalism is unique in that it is structured within the neoliberal frame in a contradictory way. On the one hand the discourse claims that regulation is undesirable and as a matter of policy seeks to reduce it. On the other a subset of this discourse praises its extent and its rigour and counters criticism by boasting of it – a good example of compartmentalisation.
Its characteristics: It is also unique in that it is structured within and controlled by the same neoliberal believers who think that it harms the market and should be reduced or abolished. In practice the regulatory processes tend to be fragmented, inflexible, and, in keeping with neoliberal managerialism. It is process driven, so impersonal and unhelpful to those on whose behalf it claims to regulate. They are poorly integrated.
Regulating aged care
Australian academic criminologist, John Braithwaite, has used aged care as a measure of the effectiveness of his theories. If they worked in this most vulnerable of all sectors then they would work elsewhere. He studied regulation by direct observation of regulators in the USA, the UK and Australia during the 1990s. He felt that this was the most challenging sector to regulate and so a test of his ideas. He was in large part responsible for developing a relatively effective regulatory system in aged care in Australia in the 1990s. This was abandoned in 1997 when the Howard government chose to use accreditation as a regulatory process instead.
Possible problems with Braithwaite: Braithwaite described the way regulation was captured in the USA and then in his 2007 book described the inadequate manner in which it was being done in Australia. He considered that it had been captured here and the process had been dumbed down. He quoted motivated staff who were frustrated by the way they were overruled and not able to regulate effectively. I am not sure that he appreciated just how extensive this was to become over the next few years although he warned that it would get worse. I am not persuaded that the "regulatory pyramid" that he advocates would adequately address this problem by itself.
At one time he advocated for a regulatory system in which different groups with different points of view all participated and constrained and balanced one another's weaknesses. The intention was to avoid its capture by particular points of view - as we are now seeing. I have not read all his recent work.
As indicated in the previous slider, I do not believe that he understood the full extent to which this had happened in the USA and Australia. I was studying corporate behaviour in the USA at the same time in the 1990s and from that perspective it was widespread and endemic.
Braithwaite and data: Braithwaite was very critical of the way data was collected and used in the USA and I agree with that criticism. I think that the problem lay in the manner in which it was done in the USA and the way that the data was used – the context. This should not be used as an argument against the collection of data and I worry that Braithwaite may think this way.
I initially thought that he supported sensible data collection but in the later works I have read he seems to have abandoned this in favour of his own theories. In my assessment this was unfortunate because data is essential to protect what he advocates from tokenism, ritualism and market capture as well as confronting neoliberal discourse, managing nursing homes and informing customers in the marketplace. We should not copy the USA but that does not mean that we don’t need information.
Braithwaite’s important contributions
Braithwaite did make a number of very important observations and very useful contributions. These need to be incorporated into what we do.
Flexible investigation: He advocated a flexible investigative and interview style of oversight and regulation that explored and assessed the subjective experiences of staff and residents so assessing and addressing the critically important “glue of life” on which care depends. Regulators followed clues to unearth deficiencies and failures. While identifying problems and being critical of them he worked constructively with the providers to address them.
Social control: He was impressed by the effective way in which regulators used personal contact, relationships and dialogue with the providers to bring about effective change.
He speaks of the effectiveness of “a dialogue that without threatening distrust, naturally exposes abuse of power to community disapproval”. In regard to regulating nursing homes he speaks of including “residents groups and advocacy groups in nursing home regulation”.
We argue that these ideas and Braithwaite’s principles are sound and would work well within a structure that takes account of the other factors that threaten to undermine it. They are integral to the Community Aged Care Hub structure that we propose.
Writing about Regulatory Capitalism and Braithwaite’s work: Braithwaite has written a large number of papers and I plan to write a separate page about Regulatory Capitalism reviewing some of his work and its importance for aged care. I will link to it from here. I have only read some of his papers and may have to revise what I have said here.
That will be a time consuming task and I am going to defer it until I have completed more of this web site.
Other theoretical perspectives
There are a number of concepts and ideas that developed in the mid 20th century that I have found useful in understanding what has happened and in managing change.
Constructing the world, creating meaning and coping with conflict
Sociologists in the 1960s built on philosophical insights to show that we understand the world we lived in through words and ideas that are related to who we are and what we do in the world. In discussion and as we grow we, as a community, a nation and even a species build sets of ideas about the way things are. One generation contributes its knowledge to the next. We talk about the “social construction of reality” and we call what we construct “world views”. Ideally this is based on the real world and represents it accurately but quite often it escapes into myth and illusion. The outcome and how real it actually is has a profound impact on who we become and the things we do.
Complexity: But the world is a complicated place so that these ideas can become complex, contradictory and confusing. We struggle to make sense of them – a state of uncertainty or anomy. Having a sensible system that has meaning for us is critically important for us as we build our lives. When it is uncertain and conflicted we can experience intense anxiety.
Responding to complexity: Because having a useable reasonably simple meaning system is so important to us and it causes so much discomfort when it is chaotic we readily respond in two ways. We commonly become defensive and hang on to the simple pattern of beliefs we already have that are being challenged. We respond by attacking our critics and defending it any way we can. This is typical of a culturopathy where believers are challenged by the adverse consequences of what they are doing. We can call this a responsive approach because it responds to threat.
Vulnerability: When we don’t already have a simple belief or the one we have is no longer sustainable we are prone to grab at the most appealing and simple ideas that are on offer and then believe in them. This can be a religious belief or an ideological system. By doing this we create an ordered world view (or nomos) where we have simple explanations. Anomy is replaced with nomos. This is why we are so vulnerable to ideologies - belief systems that create nomos but are snake oil and don’t work.
Being constructive: We can contrast this with a different approach where we become interested in the different things we are experiencing and the conflicts between ideas. We don’t feel threatened and instead of being "responsive" we become “constructive”. We reflect on the issues and explore them, building and working with new and sometimes more complex understandings. Clearly the constructive behaviour is preferable and leads to better outcomes.
Theoretical Continuums can be helpful
It is useful to build a set of concepts that describe the two ends of a continuum. This allows us to look at where we might sit along that continuum at any particular time. We can see ourselves moving backwards and forwards over that continuum. What we then become interested in are the factors that move us about on that continuum. We want to see whether we can manipulate them to create a desirable situation - one that challenges and constrains so that ideas are applied where they work and constrained where they don’t. As responsible social citizens we aspire to a way of living that works for us all and not just for a those who believe.
- Discourse: In considering Foucault’s ideas about the way discourse is controlled, at one end we have power provided by access to, censorship of and control of information. At the other we have powerlessness because of a lack of access to information and control over the information we get. This has a profound influence on how we think and understand - how we influence and control one another’s view of the way things are.
- View of the world: We have chaotic anomy opposed to well-ordered nomos.
- Behaviour: We have responsive behaviour on the one hand and constructive behaviour on the other.
- Personality: We can talk about closed minded personalities who defend their views aggressively and refuse to accept criticism at one end. At the other end are open minded personalities who are more tolerant of stress. They welcome criticism and use it to either challenge their views or to refine them.
- Identity: We have already written about inauthenticity at one end and authenticity at the other when talking about identity.
While these describe different aspects of ourselves and our societies they are interrelated.
In a culturopathy: If we consider the sort of situations or contexts that would influence these continuums then you can see that in a culturopathy the context and the pressures in those contexts are likely to foster the first less desirable item in each case.
The idea of an aged care community hub: The proposed hub was designed with these continuums in mind. It is intended to ensure that information would be available to all so that the power imbalance was neutralised and no one could control what was discussed in the discourse. This discourse would occur locally near the bedside and in the community so would be pinned to what was happening there.
The discourse would address anomy by creating a context where people would more readily know and trust one another. This would favour a constructive approach. People with Open minded personalities would flourish and succeed and this sort of personality would be fostered. It would confront inauthenticity and foster authentic identities so avoiding many of the psychological strategies used to support culturopathic systems.
To explore these ideas in greater depth Link to A socially constructed world
Enticements and those who respond to them
There are two very important additional factors impacting on the service given to vulnerable people in aged care:
- The first is the pressures in the system - the incentives and disincentives.
- The second is the sort of people making the decisions. Are they going to resist pressures to serve the company and their own advancement when this will disadvantage the vulnerable aged.
Incentives and how they work
In response to strong incentives many, if not most, of us will look the other way and find rationalisations and justifications that make doing what we are enticed to do legitimate and desirable. This, of course, is exactly what the behaviourists, who dominated thinking in the 1950s, had shown would happen. They believed that by adjusting incentives and disincentives they could make people behave and think the way that society wanted them to - and so develop an ideal society. They were very influential in psychology and education.
Behaviourism: Behaviourist theory was based on experiments in rats, showing how they could be conditioned to respond and learn to do the tasks the experimenters had set them. Behaviourism was very effective in getting children to do what the behaviourists wanted them to do and studies confirmed that it was very successful. But the world is not as simple as the behaviourists thought. It soon became clear to teachers that children stopped thinking about what they were doing and instead focused on what they had to do to obtain the incentives and avoid the disincentives.
The rat in us: Instead of reflecting about the consequences of what they were expected to do and evaluating the pros and cons of different approaches the children stopped thinking as responsible social beings. Critics of behaviourism accuse it of turning people into rats. They learn to respond to incentives and disincentives like the rats in laboratories do without reflecting on the consequences. It was gradually discredited and replaced by educational theories that encouraged reflection, constructive thought and social responsibility. Behaviousism operated at the level of the animal in us and at the expense of the reflective human that we had since become.
Computer based education was dominated by the behaviourists and this persisted for many years. The real potential of technology as revealed in the internet was delayed for 20 to 30 years. Those who recognised that potential were ignored and did not get support.
It is also clear that you cannot design a simplistic world in which all the incentives and disincentives are aligned. You require judgement and insight to decide how you will navigate this and what the other consequences will be. There are always pressures that have to be considered, evaluated and rejected.
Humans and reflection: We humans are animals too and respond to pressures in the same way. Humans, unlike rats, have the capacity to reflect on the logic and the consequences of what they are being asked to do. But they have to develop this additional capacity and learn to use it - much of it is socially acquired. Like all socially acquired characteristics it needs to be used and socially reinforced.
Incentives and disincentives all too often cause people to ignore logic and conflicting information and do what the pressures dictate. People who use incentives and disincentives to get others to do what they want can have objectives that turn out to be dangerously dysfunctional for society. Even more importantly incentives and disincentives actually stop us from reflecting and considering the implications of what we are doing. They put pressure on us to behave in a closed minded way that ignores the consequences of what we do.
Incentivisation and neoliberalism: It is interesting that behaviourist principles have been extensively adopted in the neoliberal marketplace and have been very successfully used within the neoliberal discourse. Potential employees look carefully to see what incentives they will be offered before they apply for a job. Those companies that use incentives based on profitability have been very successful. They have also been those who have most often exploited the vulnerable and indulged in fraudulent and socially undesirable conduct. Look at what happened in the financial advice sector and in the banks. It is clear that incentives and disincentives turn people into rats in the marketplace as well.
Applying this in the marketplace: We can look at how this works in the marketplace, the different sorts of incentives and disincentives that operate there and ultimately at the use of kickbacks and their impact in the marketplace. We can see how this fits into the top-down organisational structure of the companies and understand why people can come to behave like rats.
Ross Gittins, the economics editor for the Sydney Morning Herald, is very critical of current economic thinking and the application of simplistic economic formulas to markets where they don't work.
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
In health care: Incentives (called kickbacks) have been recognised as a problem for a very long time. In the USA the Stark Laws specifically banned kickbacks to doctors. Almost every other country has followed suit. Corporate Healthcare in the USA has devoted vast amounts of effort to hairsplitting. They have tried to create 'legitimate' incentives which legally are not kickbacks but which operate similarly. There are no restrictions on other staff. Managers have score cards or similar and incentives are tied to economic performance. The majority of major frauds in the sector are incentive driven and charges often include the use of kickbacks.
Incentives vs rewards: There is a distinction between incentives and rewards. Incentives because of their nature are narrow and specific whereas rewards are broadly based for well-motivated people who have done well. People are not focused on the reward but their good work is acknowledged. The impact on humanitarian motivation is very different.
There are of course intrinsic incentives and disincentives in every situation which we need to reflect on and evaluate when we make decisions. Once again the problem is taking something normal out of its controlling social context and turning it into something excessive and harmful in a context where it is seen as desirable and acceptable.
There is more about this with examples on the linked page Why we behave badly
Nature vs Nurture
We must finish off by looking at the issue of Nature versus Nurture. Are people born bad or do we make them bad because of the sort of environment we place them in? If they are born bad is there anything we can do about it?
Well it turns out a bit of both. We can be born bad and sometimes we can do something about it but probably not always.
Bad genes and nurture: Studies have been done by psychologists on a group of dysfunctional people called sociopaths. They are unable to empathise and understand the consequence of their action on others. Many end in prison, sometimes after a particularly grisly murder. Studies have shown that these people have changes on brain scans. They have also found that they have a pattern of inherited genes. The most important of these is called the 'warrior gene'.
But the warrior and other genes are also found in normal people in society, who mostly behave well - although their behaviour can sometimes display some of the same characteristics.
The studies show that although these people all have the genes, its the environment, their upbringing and the situations in which they find themselves (the incentives there) that ultimately determines whether the genes are expressed or whether they remain dormant. So we can reduce the expression of the warrior gene if they are reared in an environment and find themselves in a society that inhibits its expression and encourages responsible behaviour. Its far from certain that we can always do so.
Successful sociopaths: A subgroup with the warrior gene are called "successful sociopaths". They are not violent killers but intelligent charismatic manipulators who do well in society, particularly in business. But because these people lack the reflective ability and conscience needed to consider the consequences of what they do, others are often harmed or defrauded.
The researchers found that only a little over 4% of business owners can be classified as successful sociopaths so we cannot blame what happens in all culturopathies on them.
What these studies do illustrate is that we all come with a complex variety of genes that effect our behaviour. Sociopaths are only one facet of that. These genes will be expressed when the people who have them find themselves in situations where these genes give them a competitive advantage. This is why we are such a versatile species and why some of us can always prosper as individuals in whatever situation we find ourselves. Some will have the genetic makeup needed to prosper there and others will not.
Evolution is concerned with the survival of the individuals of the species at the expense of those who cannot survive in that situation. It does not have a social conscience and those of us who have may need to step in.
Sociopaths and aged care: We don't know what the incidence of the warrior gene among senior health and aged care executives is as no one has studied it. We can argue that vulnerable sectors like health and aged care provide greater opportunities for expression of the warrior gene. Being able to ignore the consequences of your actions gives you a competitive advantage in this sort of market. But we simply don't know.
In 2001 long before we knew about the warrior gene or that there were detectable brain changes I wrote about successful sociopathy - at that time positioning it at the extreme end of Closed minded behaviour. At the end of that page (Introduction to Sociopathy) I put links to many of the corporate executives whom I had written about All we can do is look at what we know about them and guess at who might have had the warrior gene if they had been tested.
Learn more: To explore these ideas in more depth Link to The warrior gene
Implications for vulnerable markets
I have long argued that the unrestrained free market in vulnerable sectors selects for the least suitable people to provide care and gets rid of the most suitable. Some of these may be sociopaths, others simply one eyed and closed minded. They are successful economically and become credible leaders because of that and not because of the care provided. Whether we behave like rats or become reflective is not closely related to intelligence but it impacts on the way intelligence is used.
Intelligence can be used to rationalise and justify what the rat in us wants to do, or it can be used to understand and reflect on the consequence of what doing that will do to others and to consider our social responsibilities. Very intelligent people can be very successful at being bad.
People whose genetic code and cultural backgrounds predisposes them to become reflective and to be empathic and more conscious of what is happening to others will challenge the incentives. They will feel uncomfortable and either go elsewhere or rebel and be thrown out.
A desirable aged care system
This section has looked at the undesirable characteristics and problems in the neoliberal designed aged care system. It also allows us to look at the ideal sort of aged care system that we would like and at what we would like it to include.
We might imagine an idealised system that fixes the dysfunctional market. It would be a more stable market that provides services and does not commodify frail and powerless people and trade them in the marketplace. It would conform to established market theory by having effective and knowledgeable customers choosing wisely, and actively involved communities that set the limits of acceptable conduct.
An ideal system based on the contents of this section
We would envisage a system where community was responsible for the care provided to its members including care provided on its behalf by others. Success in the marketplace would depend on responsibly identifying with community values, norms and an empathic approach as well as the nature of the services given.
Such a system would ideally be managed and structured locally close to the services provided so that exactly what was happening there would inform discourse. Information flowing up the system would confront and modulate policy.
It would be characterized by
- A discourse that was built by those close to the bedside and based on what happened there. It would focus on the needs and welfare of those receiving care rather than on the needs of the provider - while being constrained by what was possible. It would exert its control up the system rather than down it.
- A system where available resources were maximised efficiently for maximum service rather that maximum profit.
- Marketing and hype would be constrained by reliable information and tokenism would not occur
- The most desirable and effective sort of care and the relationships that make that possible by managing power and dependence can be developed and provided
- An oversight and regulatory system that met the principle of distributive justice and that capitalized on close regular contact and the power of personal relationships and discourse near the bedside. Response to identified problems would be immediate and ongoing. It would be supported by a formal responsible regulatory system that was independent of any particular discourse.
- The collection of necessary data for the management of facilities, for an informed market, for informed policy development and to anchor regulation, oversight and discourse to reality.
- Placing this within a wider system of general oversight would prevent data becoming ‘indicators’ that distort the service provided
- Data collection and oversight shared by all parties that was ongoing and accessible for use by all parties and part of the delivery of services would cease to be burdensome.
- An interactive social context in constructing and reconstructing the ‘worldview’ within and about aged care. This would be constructivist in its handling of uncertainty, complexity and conflict. Shared knowledge would give a balance of power. Behaviour would be constructivist and open mindedness the norm. It would be a context where rewardingly authentic identities could be built.
- Where responsibility and humanitarian considerations would be the driving force motivating providers. Deliberate incentivisation would be stigmatized.
- Where genes that favour responsible conduct would be expressed and those that turn us into rats suppressed.
- A system that fosters the best in us and that selects the most suitable to provide services rather than the least.
- A constructivist context of regular and ongoing discourse where
- The maximum responsible use of available resources for maximum benefit was a critical consideration but was balanced against the community’s ability to deliver the resources needed.
- a shared discourse would be developed so that there were common objectives
- the discourse would be continuously reassessed as circumstances changed and multiple points of view would be brought to bear
- It would be very difficult for the discourse to escape into illusion and emotional snake oil. It should take what is relevant from new ideas but prevent ideology developing within it or once again threatening it from outside.
Is it attainable?: Ideals are seldom if ever fully attainable but we progress by moving towards them and adapting as we progress. The argument is not that all our ideals can be met but that the current neoliberal market-centric aged care roadmap makes it almost impossible to attain any of them.
A community-centric roadmap focusing on the care and wellbeing of its most vulnerable citizens would create a context where strategies could be readily developed not only to attain these objectives but also the lofty objectives of control and choice. These two very different roadmaps based on different discourses are compared on the Aged Care Roadmap web page in the introduction.
There are major difficulties in changing a community that has been socialized into an individualism that is driven by self-interest and success often in serving the interest of other individuals or corporations – one that seeks personal financial rewards for whatever it does, and that looks to government to manage all its affairs and blames it when this cannot be done.
Then there is the generation that has grown up in this world and has been deprived of the role models and socialization that sees value in serving others. It is characterized by the image of the ‘selfie’ and the sound grab – a reflection of its desperation and exclusion from a discourse that finds meaning in community and in our humanity.
It will be a formidable undertaking to turn this into a society that finds meaning and worth in responsible citizenship and in engaging in discourse in a ‘truly civil society” - one that takes responsibility for managing its own affairs and learns the intrinsic rewards of involvement and the development of social selves.
This is no mean task but its potential benefits make it an objective worth pursuing and aged care is a good place to start. It must be done with great care by engaging and building and not by marketing an image.