'world class care' ... or is it?

Australian Aged Care: 'World Class' ... or is it?

Austrade: Aged Care

There are very different understandings of the way the aged care system is operating between the different groups that are interested, including the general public. This is at least in part because there is simply not enough reliable information available about what is happening in the sector. This fuels the perception that there is much that "they" don't want us to know.

It may be that government and the industry are simply blind to what is happening or that the multiple reports of poor care and disturbing cultures are exaggerated. But we don't have the information needed to resolve this. In fact, we have hardly any useful information. The information we get is so tainted by misrepresentation that we no longer believe it.

I have closely examined similar situations in health and aged care and in my view it is unlikely that the government and industry are correct. While there will always be some misunderstandings, I have never seen so much smoke without a large fire.

The sliders on this page: I could go back many more years but have only selected two examples in 2007. This shows that there were wide differences in viewpoint then. The other examples are more recent and the complaints are unchanged.

The section/slider 'The Age Well Campaign' explores different views of the 2012 Age Well Campaign that was based on the 2011 Productivity Commission Report.

The way in which the industry and government ignore and fail to address public exposure of issues as well as key community concerns is illustrated by a 2015 example.

In 2014, COTA promoted the government's inclusion of aged care in trade agreements with China. I contrast COTA's views of our aged care system with those of other senior's groups.

The recently rebadged Australian Aged Care Quality Agency's claim to steadily improving standards of care in Australian nursing homes over the years is contrasted with what others are saying about the system of accreditation of aged care homes.

The final slider is a selection of typical comments coming from the community.

I round off the page by looking at the key issue of staffing, which comes up repeatedly and where, unlike those countries where aged care research is done, there is no information to research in Australia.


Australian Aged Care: 'World Class' ... or is it?

We are confronted with claims to high standards and a world class system.  Do we believe that or should we listen to what people who see what is happening are saying?

Australia: 'Setting the Global Standard' in aged care?

The wishful and illusionary thinking about aged care is reflected on the Australian Trade Commissions Austrade website.  The claim to world class care is suggested in the title 'Setting the Global Standard for care'.  It is just as well that the Chinese did not ask for actual data to substantiate that claim.  That would be difficult to sustain when you consider the absence of data and the groundswell of critical comment.  

The Australian aged care system is a global benchmark for best practice, thanks to strong government funding, a robust framework for accreditation, quality and regulation, and a long history of cooperation between government, service providers and the community.

Australian capabilities span infrastructure, services, products, technologies, research and development, education and training. Dementia care in particular is emerging as a health priority, and the Australian aged care sector has developed services and resources to meet the demands of a growing number of older people with dementia.

All these capabilities are supported by a world-leading legislative and quality framework, as well as substantial investment in research.

Talk to your local Austrade representative for more tailored advice and information on connecting and partnering with the Australian aged care sector.

Australia has developed a sophisticated system to deliver multiple levels of care to its ageing population and is investing strongly in resources and initiatives to support older people, carers and families.

Industry Strengths: The aged care system in Australia is one of the most thoroughly regulated in the world and is used as a model by many other countries.

Source: Aged Care Setting the Global Standard for care Australia Unlimited.  The Austrade web site

Its all about seizing opportunities by selling their illusions to the Chinese.  

- - -  in Robb's grand vision – many, many more services to a rapidly expanding and already massive middle class market in China.

The Business Council of Australia is among those keen to emphasise how important unlocking such a vast new market for services could be for this country. President Catherine Livingstone says the Chinese middle class will want the same valued-added service in professional services, finance, health, education and aged care that already underpins around 80 per cent of the Australian economy.

Source: Chinese dreams, Australian reality with free trade deal  - Australian Financial Review, 17 Jun 2015 (Paywall)

The one thing that is clear is that this is all about impression management and making money. It has very little to do with how that is done - with actual care. With such financial enthusiasm companies will be promising investors vast profits. They will be going in there to make as much money as they can in order to fulfil their promises and their responsibility to their investors. At this stage, we can only ponder what the outcome for the elderly Chinese who swallow all this rhetoric will be.

Trifecta policy conundrum?

(A) Clamping down on rorting whilst simultaneously (B) promoting an 'excellent aged care system', (C) an 'export earner': In a December 2015 report in which the current minister claims she is clamping down on rorting to preserve the integrity of our excellent aged care system, this is what she said:

She said the scheme had helped ensure Australia's aged care sector was one of the best in the world, making it the envy of other countries and therefore potentially an export earner.

Source: MYEFO budget update: Big fines aim to stop fraud in aged care - Sydney Moring Herald, 15 Dec 2015

So, is the governments competitive marketplace policy intended to use the competitive pressures they believe in to improve our care as claimed - or is it to create an "export earner"? 

Is this a Freudian slip of the tongue showing how she thinks and the pressure put on her from colleagues whom she must please to keep her job?

In September 2016 the Trade minister is helping our companies exploit the enormous opportunities:

Today I launch the report Health and Aged Care Industry in China: A Guide for Australian Business, which outlines the key opportunities emerging from our biggest trading partner.

In responding to this demographic shift, China has embarked on fundamental health and aged care reforms through its Healthy China 2020 strategy. This strategy proposes a role for private enterprise and foreign capital in developing China’s health and aged care sector and also aims at a target of 10 million aged care workers by 2020.

Source: Millions of Chinese need Australian health and aged care skills - Trade Minister Media Release, 15 Sept 2016

Sacrificing the wellbeing of the aged to the economy

Ministers have made it clear that they plan to solve our economic woes by selling our services to others. To do so, Australia needs large consolidated market savvy profitable corporations. We wonder to what extent the economic needs of Australia are the driving force behind the government policy of marketising and consolidating our aged care system and making it economically efficient? 

Is this why they are selling us the new "Living Longer Living Better" market system and why the extra money provided in 2014 seems to be going to profits, listing on the share market and on employing consultants to provide training in financial amd marketing skills.  At the same time, staffing levels and other costs are being reduced.

To those who have looked at the evidence, it is clear that Australia is sacrificing the care of its own senior citizens by introducing a system that has been known to compromise care for at least 20 years.

Is it doing this knowingly and deliberately? Politicians cannot be unaware of it.  Or is it simply that they are unable to acknowledge that they know because they are locked into policies that dare not change and if they acknowledged this then they would have no choice but to change.

What actually happened is revealing.  For both China and Australia, it was all about markets and competition. The potential consequences for the frail elderly were not on the table. Their needs were incidental to the needs of the economy.

He'd (Rob - trade minister) come to the view that the big opportunities for Australia's future lay in selling services to the world. Three quarters of Australia's economic output is services, not goods.

The Chinese refrain: If we allow access to Australian services, then eventually we have to give the US and Europeans the same, and they are so big they will swamp us.

Then Robb had a bit of a brainwave. "I saw Gao over a meal in September, and I said to him, 'I've been impressed with China's Special Economic Zones'," areas of the country where the usual regulations are suspended to allow greater freedom to foreign trade.

"I said to him, 'You ought to think of Australia as a special economic zone for services. We've got a population of 23 million – that's smaller than some of China's special economic zones.

"I put the idea to both of them (two senior chinese politicians). Then I sat down with Gao to negotiate 10 days later and the doors just opened on services." Beijing offered unlimited access for Australia to build private hospitals, aged care homes, hotels and restaurants, with 100 per cent Australian ownership.

Source:  Profiting from the trading post Sydney Morning Herald, 26 Jun 2015

Encouraging companies to take the plunge

I wonder if the big for-profits have reservations about this as none of them are mentioned in the reports. The articles below could be to encourage them and give them a push.

International Opportunities in India

An article the LASA periodical Fusion (Autumn 2015) describes the visit of the Trade Minister, Andrew Rob and a team of executives to India where Free Trade Agreements are commencing. The article indicates that "it was very important that Aged Care be a part of the conversation. We joined health - - - to meet with our Indian counterparts, to discuss shared issues and areas of potential collaboration". "Indian businesses are interested in partnerships, joint ventures and investment opportunities in Australia" and for those interested in the Indian market "there has never been a better time to engage".

The article looks at the ageing of the Indian population and then drills down to look at the commercial opportunities in the middle class but particularly among the wealthy. The article goes on to list "a range of opportunities for Australian businesses and organisations". It seems that UK and US companies are already operating there.

And in China too

And in 2016 the Australian government agency Austrade is advising that "those interested in entering the 'complex market' should go in early". It urges "providers to find the right partner in China and enter the market with a long-term plan". It is interesting that it is a faith based not-for-profit that is the public face of this in the linked article. But the deal is to train Chinese by an "advanced aged care professional skill training and work placement program" to be delivered in its Australian hospitals. Another not-for-profit NFPCompanyß has partnered with a Chines organisation in 2014 to actually provide home care services in China. We are left wondering if any for-profits are planning to enter the country and compete with UK and other multinationals in providing services locally.

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Industry vs aged care critics

Like most of those who look at what is happening and become alarmed at what they see, it was the death of her father from an infected pressure sore, which should never have occurred that prompted Lynda Saltarelli to look at what was happening in nursing homes.  She then  researched and talked to others.  What she found led her to found The Aged Care Crisis centre.  

Failures in aged care

She wrote a carefully researched article which was published in The Age in November 2007. As revealed in the article, she spoke to many others and heard what was happening first hand.  No one could seriously have questioned her integrity and you would have thought that the bodies representing the industry would want to talk to her and then go out and verify it.

Our grief was unnecessarily prolonged by the circumstances in which my father died. I wondered how often my father's experience was being repeated around Australia. That's how I became an aged-care advocate.

My father's experience taught me just how ill-equipped most families are when it comes to aged-care issues, having to make tough decisions with little or no knowledge easily available. Our Government boasts about the "booming" economy, but many frail Australians live in totally unacceptable conditions.

There is evidence that residents of aged-care facilities regularly go without proper pain relief and palliative care. Failures include poor infection control, inadequate clinical care, failure to provide safe medication management, and inappropriate use of physical and chemical restraints.

Some patients, who were previously without skin conditions, were returned to their nursing homes with skin tears, bed sores and bruising from rough handling.

On the other hand, hospital specialists openly report that they see residents admitted suffering from malnutrition. For example, Royal Perth Hospital aged-care services physician Roger Warne has said the "revolving door" of malnourished elderly patients was partly because of inadequate staffing and training in nursing homes.

Melbourne's Austin Health Hospital aged-care director, Michael Woodward, states "people were dying of malnutrition in nursing homes across Australia".

Little surprise, then, that residents and relatives are the ones most likely to expose deficiencies in aged care. They have neither business nor political interests at stake, and they suffer most when it fails. They are outraged by breaches in care when these reflect a failure to serve the community's values. Too often the bureaucratic complaints procedures fail and justice is denied.

The devil is certainly in the detail — political parties have yet to respond with policies that tackle many of the following unresolved issues in Australia's aged-care system:

  • Greater accountability for the treatment and care of older and frail citizens in aged-care facilities.
  • Many homes simply fail to employ enough staff to sufficiently feed, clean and care for the elderly.
  • Increase the level of transparency within the accreditation system for consumers — accreditation measures what providers say they do and not the standard of care they actually deliver.

Fear of retribution is one of the biggest and unaddressed reasons for the failure of all the reinvented complaints schemes. Staff fear for their jobs, and relatives are reluctant to complain fearing the care of their loved ones may be compromised.

Source: Vulnerable elderly deserve better care - Lynda Saltarelli in The Age - Opinion, 19 Nov 2007

Lynda was saying in 2007 things that critics had been saying for some years and they are still saying it 8 years later.  A vast amount of information now substantiates the serious concerns. 

Industry denies failures in care

The only response Lynda got from the industry was a comment from ACSA CEO claiming she had missed the point.  Decide who actually missed the point:

LYNDA Saltarelli (Opinion, 19/11) has unfortunately missed the central point - Australia has one of the most robust accreditation and complaints systems anywhere in the world.

The aged-care industry is highly regulated and accountable. The introduction of legislation to deal with elder abuse, our 44 accreditation standards, police checking and new complaints system demonstrate it isn't regulation or accreditation that is the failure in aged care.

Our dedicated workforce is increasingly pushed to breaking point because of the failure of government to provide funding that meets our rapidly rising costs.

In Victoria alone more than 45,000 of our elderly live in residential aged care. While their families recognise the industry's commitment to a high quality of care, they know our elderly deserve more. It is here that neither Labor nor the Coalition has any tangible plans.

The next elected government must provide much needed additional funding and address our impending workforce recruitment and retention crisis. They ignore these issues at their peril. We have to prepare for our future, today.

Source: Gxxxd Mxxxx, chief executive, Aged and Community Care Victoria, Melbourne

I think that it was Mxxxx who had missed the point, or more probably, was simply not prepared to look at it. Everything that Saltarelli said in that letter still applies today, and has been complained about over and over again.  If our system was so robust, then it would be collecting the information needed by residents and also by those assessing the performance of the system in order to respond when making policy.

I will show on other pages that ACSA has continued to deny. It tries to ignore what its critics say and when they are insistent, ACSA has attacked their character in order to avoid addressing the issues. 

What is more, the "robust accreditation and complaints system" is considered to be a farce by those who experience it. No one is happy with it - yet the industry continues to make these ridiculous claims about its efficacy.  This is intolerable and as a community we have to stop it and take control ourselves.

We have learned from Aboriginal Health that there is no point in throwing money at something that is not working. Money may be a major problem, but you need to first have a system that works for those it is intended to serve.  Money thrown at the current system may help companies to grow and to list on the sharemarket, but it won't go to staffing and it won't help residents until it is profitable to do so.

Here are some more examples of industry response to criticism

Critical TV programs: Channel Seven's Today Tonight published a program "Nursing home shame" describing  'neglect at epidemic levels' in Australia’s residential aged care sector, including poor quality food and widespread malnutrition." 

As the industry were well aware, this was only one of many ongoing allegations about poor care, food and malnutrition and there is much to indicate that it is widespread.  Those allegations are ongoing and recurrent.  Mxxxx by now, CEO of the industry body LASA, responded and Prof Jxxx Kxxxx from ACSA joined in:

Mr Gxxxd Mxxxx said the program lacked any context at all and was a 'nonsense story' and should be treated that way. - - the most challenging and highly regulated industries in Australia, - - isolated cases of poor quality care - - - cases of homes being sanctioned by aged care authorities, was proof that the system is working to ensure the highest possible standards of quality in aged care. - - - well over 95 percent of all 2,800 homes Australia-wide are fully compliant with all 44 accreditation outcomes. This is an outstanding achievement

- - - This is not journalism; Channel Seven has no credibility in calling this an 'investigation' into aged care. There was no effort to contact the peak associations or find out any real facts about the current reform issues or viability concerns or anything other than  perpetrating an old myth.

- - - And while I am in this role, I won’t stand for that. It is entirely unreasonable. I will back the professionalism of our providers and their staff any day.

Adjunct Professor Jxxx Kxxxx (from ACSA), representing charitable aged care providers, also criticised the program for 'trashy, sensational reporting' and poor journalism. - - - portray sensitive issues in an emotive and sensationalist way.  This sort of sensationalist stuff encourages people to have a view about the quality of care in the aged care sector that is totally incorrect.

- - - “The fact that over 95 per cent of aged care providers meet all 44 accreditations standards speaks for itself.  We would support any investigation into isolated reports and complaints.  These are part of the robust quality control system we have.  It’s so poor, it’s dispiriting.  There are so many important messages that the community needs to understand about aged care and this is what they do.

Source: Peaks slam Seven's Today Tonight: 17 Jul 2012

I recall that program and agree it was poor - but those allegations are the same ones that have been made many times and are still being made. The defensive response fails to address the fact that these things are occurring and seem to be occurring far too often. 

Instead of collecting data so that we know what is happening, we have a system that focuses on processes and fails to collect, measure and publish the data needed to determine the success or failure of these processes - nor to give the public the information they need. In the face of so much - and such continued criticism denial is not an acceptable response.

Assaults: In an article "Aged-care assaults increase" in the Sydney Morning Herald those who had been listening to families and staff questioned how effectively "nursing homes were being monitored given the volume of complaints - - -If the facilities are so fantastic, why are so many people complaining and why are there so many reports of abuse? - - -  Nearly 70 per cent of aged care complaints impact directly on the health, wellbeing and human rights of residents in aged care, -  -"

Gxxxd Mxxxx, the chief executive of the peak body representing providers, Leading Aged Services Australia, denied that quality was declining.

"Overall the industry has an outstanding quality record as measured by our independent accreditation scheme, under one of the most robust quality systems anywhere in the world," he said.

"Where there are isolated incidents, these are treated seriously and acted on promptly by providers even when it means reporting allegations or suspicions. The data reveals that many assertions may not ever be substantiated."

Source: Aged-care assaults increase - Sydney Morning Herald, 30 Nov 2012

Problems in Queensland in 2015:  This is the response of the industry to serious allegations about care in a Queensland not-for-profit in early 2015. The Quality Agency claimed that it had found problems in a majority of the groups homes.  The group strongly denied and challenged these assessments. It took the Quality Agency to court and showed that it had been unfairly treated.  It then claimed it had been completely vindicated.

In addition to these allegations, there were allegations from nurses who had worked in the system claiming that the problems were widespread and consequent on the commercial focus of providers.

The point I am making here, is that there were wide differences of opinion and no one was actually collecting hard data. 

The industry's response was denial, when what was needed was support for an independent and accurate measure of performance in the sector.  What we saw was allegations based on fragments of unreliable information collected by a small number of random snap shots. 

We have no record of what was happening in these facilities on a long term basis.  But the industry went into defence mode. The interests of the elderly demanded that these be seen as red flags.  They should have been considered as such until disproven.

Recent media reports suggesting abuse, possible death and cover up at a residential aged care facility in Queensland go against the vast majority of age service providers efforts for older Australians, according to a peak industry body (LASA).

“As a body for aged care providers, Leading Age Services Australia’s (LASA) top priority is high quality care and services that not only meet the needs of older Australians but ensure they live well,” says Pxxxxxk Rxxd, LASA chief executive.

Another peak body for aged care services, Aged & Community Services Australia (ACSA), claims it is "unfortunate" that allegations such as these arise from time to time.

Adjunct Professor Jxxn Kxxxy AM, ACSA chief executive, claims the article in The Australian raises issues of concern.

Source: Aged care abuse allegations 'unfortunate' Aged Care Guide.com.au Feb 2015

Response to a growing number of allegations: For 19 years the industry has been hiding behind a fatally flawed oversight system. Instead of confronting its inadequacy, it has been hiding behind it and denying the obvious.

These responses are so forceful and so indignant, that there seems little doubt that these people and the bodies they represent are sincere, genuinely believe - and are furious about anyone reporting information that they consider false.  They don't see it the way we do. 

But people report information and go to the press because the industry is not listening. In fact, the whole sector, including the politicians representing the community in parliament, are not listening.

To critics, it seems incredible that these people who, as they see it, have so little grasp of what is happpening in the the sector are promoted and have stellar careers. Worse still, they are being put in positions where they are responsible for dealing with those who are unhappy with the system.  Mxxxx went from being CEO of ACSA and then LASA to representing Senior Victorians as Commissioner - a case of putting the fox in charge of the henhouse - and so keeping it in the family.  

Victoria’s first ever Commissioner for Senior Victorians, Gxxxd Mxxxx, was appointed on 12 September 2013.  

The Commissioner has chaired a Ministerial Advisory Committee for Senior Victorians (the MACSV) which provided independent advice to the Minister for Ageing on the impacts of policies and programs relating to the participation of senior Victorians.

Gxxxd Mxxxx is a highly respected and passionate advocate for the needs of older people. With over 25 years of leadership experience within the aged and wider community services sectors, Mr Mxxxx contributed significantly to industry capacity building, policy development and enhancement of services for older Australians.

In 2012, Mr Mxxxx became the inaugural national CEO of Leading Age Services Australia, the peak national body representing the aged and community care industry across Australia. 

Prior to this, Mr Mxxxx was the CEO of Aged and Community Care Victoria for six years. Mr Mxxxx says a priority is the focus on quality of life, workforce participation and access to services for senior Victorians. This means maximising opportunities for all, including those who are marginalised or disadvantaged.

Source: Commissioner for Senior Victorians Seniors Online Victoria 12 September 2013 accessed 4 June 1015 (No longer available See here for current page)

I am not questioning Mxxxx's committment or belief in what he is doing, but belief is not a measure of aptitude or suitability.  Surely, someone would ask whether the attitude he adopts when confronting critics, would qualify him for this post. How will be respond to seniors who are critical of aged care?

Understandably, critics of the system see these people as malign and the system as corrupt and self serving. Mxxxx's appointment would be seen by many as a strategy to head off criticism.

It is only when we look around and see how often this sort of thing happens, and get close enough to them, that you realise they are genuine and actually believe in what they are doing. Coming to grips with that and trying to understand why and how this happens is more complex.

The industry lets the cat out of the bag

The industry and government have been praising the accreditation system and its claimed role in giving us a 'world class' system for 19 years. It is interesting that one of the big providers has decided to bag it. The CEO of one of the largest for-profit advisers has admitted that it is not working and is about the minimum possible and not about quality at all. In doing so, he confirms that they have been deceiving us about this for years.

The CEO is using it as a justification for the mantra of choices and more services - to get more money from individuals without any checks or balances. The government has now cracked down on financial rorting. The industry now turning to vulnerable seniors and creating opportunitries for more money.

The regulations governing aged care have served to keep sector quality at the minimum acceptable standards, but the unfolding reforms mean providers will have to innovate in order to survive, a sector leader has said

- - - little incentive for providers to improve their offerings above minimum safety standards, given consumers had little real choice between services, according to Gxxx Bxxxxxxx, CEO of FPCompany NewnameC Aged Care.

“Providers need to find ways to encourage consumers to invest in their own care or else they rely on government funding that won’t keep pace,” he said.

Source: Regulations kept aged care at ‘minimum acceptable standards’ - Australian Ageing Agenda, 30 Aug 2016

The CEO went on to explain that "Australians were used to accepting the minimum acceptable standard and were struggling with the concept of having choice and paying for extras".

Odd that the entire family (industry and government) have been telling us all that this is what is producing a 'word class' system and how rigorous it is.

Admitting they have all been lying to us

So, is this CEO and his company now being a whistleblower, a rat dobbing on his mates and betraying the rest of the industry and the government that has supported them. It certainly looks like it. But perhaps it is not intentional at all.  Perhaps they have all been deceiving themselves for years.

In the previous section Cultural Perspectives on the page Culturopathy: A for-profit example I explained how in a culturopathy, believers avoid the intense discomfort created (called dissonance) by contradictions in what they are expected to believe, say and do. They cope with this by putting conflicting ideas into separate compartments, each with its own internal logic, and don't confront the contradictions between them. I also explained how they lie to themselves.

It all becomes a game using words as tokens. They are simply part of the game and no longer attached to anything real and without emotional content. They pull out the bits that they need for the next move in the game - in this instance they need more money from a gullible public. I suspect that this CEO is totally unaware that he is contradicting himself and betraying his colleagues.  All that is in another compartment so he does not see the incompatibility.

Another example: A founding director of the company Tenet/NME that I used as my example of a typical culturopathy did the same thing regularly. He was later confronted in a court case with the contradictory statements he made in Australia.  He explained that he was simply "singing to the choir". He saw nothing wrong with this. This was legitimate in his world.  He was simply playing with words.

This is a good example of how people lie to themselves even when they know what they are doing (called bad faith). They have insight intermittently but don't use it. Its a strange phenomenon and not easy to come to grips with. I think this is what is happening here.

The proposed Community Aged Care Hub

It is difficult to believe that the two sides of this debate are talking about the same aged care system and are living in the same world. The problem I believe is that they do live in very different conceptual worlds and that those in these different worlds don't see the same things. In addition to that, the frameworks for discussion that you need for debate are not there. 

As is revealed in the extracts above, they talk past each other and don't see or hear the arguments.  It is usually the more dominant group that does not hear what it does not want to hear.  That is a central characteristic of what I have called a culturopathy.

Human behaviour: They are behaving like all humans do when they interact with the system from different contexts. One group is from management or talks to managers. The other is either involved or is talking to people who are in regular day to day contact and discussion over what is happening at the bedside.  They are all looking at the real world but each from very different positions so do not see the same things. You can only see what is visible from where you are standing and when you cannot see something that the person next to you can see you don't believe them. This is not a unique problem, it occurs in many social situations, particularly those that are dysfunctional. 

This may not be easy to accept or to understand.  Until we learn to see the world through the eyes of others we all tend to see what we expect to see and want to see. It is only when people communicate directly in the processes of life and have to deal with issues together that we learn to see through the eyes of others and through their minds. We come to see what they see. 

The proposed hub requires participants to engage and learn to see through the eyes of others. It is what the hub is directed to achieving.

The other factor here is the power and information imbalance. This is a problem to be overcome.  The more powerful automatically set the frames of discussion in any conversation. It is the frames of discussion that shut out alternative insights and arguments or make them illegitimate. Simply inviting discussion with the community and creating a forum to do so as ACSA is trying to do is not always productive. Too often people are unhappy but have not formulated their concerns so the responses are disjointed and the dominant group is not impressed. 

Community debate: The community itself needs to get together, analyse its experiences and structure its ideas and understandings so that they can express and argue them logically.  Until they do that they will be at a disadvantage and remain relatively powerless.  Their unstructured views will be difficult to argue and be easily discredited.

This is why the community needs its own forum to debate and formulate ideas. It needs to examine what the industry is doing and saying on its own terms and bring that alternate perspective to the debate. It takes time and effort to develop.

It may be very obvious that something is dysfunctional, but it is very difficult to confront and challenge a belief system from within that system because each belief system contains its own logic and that logic justifies and protects it.  Different outside perspectives are needed to illuminate the flaws, inconsistencies and failures. The utility of the original belief system can then be recognised, its problems identified and circumvented - or a better system adopted.  This web page comes at the problems in aged care from different perspectives and I think it exposes the failures and the reasons for failure.

This is why randomly meeting ACSA's invitation to discuss will have limited benefit and why I am trying to initiate a separate discussion on the Aged Care Crisis website.   So we should contribute to the industry's discussion and we should invite them to contribute to ours. Both sides will then be looking at the other's point of views and their structured arguments. 

A written discussion at this time avoids the pressure from dominant and assertive personalities and ensures that debate is considered, factual and logical. Once key differences are clearly defined, then actual face to face discussions become more useful.

Hopefully we can move towards a situation when we can look at ourselves through the eyes of our critics and see differently.  We can see the strengths of their arguments and illogical assertions will not be credible.  Denying allegations without good reason and attacking the messenger would become very counterproductive and ineffective.

The proposed Hub: That is also why the Community Aged Care Hub needs to be a separate organisation to those providing services in the marketplace. It needs standing and legitimacy as well as its own central organisation and role.  But it should be closely involved in the nursing homes and have a definite important role there so that it develops the knowledge and the judgement needed to act for the community.  That interdependence ensures that each side must confront and address the concerns and point of view of the other and come to respect it.

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Government vs Aged Care critics

As indicated, the response of the industry and of politicians has often been to point to the stellar performance across the board in accreditation ratings and claim that Australia has a 'world class' system.  They have doing this since 1997 and are still saying it in the face of evidence 19 years later. 

If you say it loudly and often enough, then the words become the meaning and anyone who suggests that they don't represent this selfevident situation is not credible.

2016: 'World class' system? Not really

The aged-care system in Australia is a world-class system. It is well respected, with high-quality services that work to meet the needs of a very diverse population. It is the envy of much of the world.

Source: Speech by Nola Marina MP Member for Forrest and Chief Government Whip - Aged Care Legislation Amendment (Increasing Consumer Choice) Bill 2016; Second Reading Hansard, 2 Mar 2016

The irony of this claim is that the example from her electorate that she used to illustrate her point had failed 9 accreditation standards only 4 months before and was at the time being supervised by her government's Quality Agency.  

Another from her electorate that she praised in parliament in 2015, also had problems with accreditation, was at the time under investigation because of serious allegations and its board was about to be suspended because of the findings. 

If these were the best examples this senior MP could find, then we clearly need to be very worried not only about aged care but also about the state of our political system and those who represent us.

2006-07: Claiming failures in care are 'rare exceptions'

Politicians like John Howard claimed that confronting scandals (eg rapes) are rare exceptions in an otherwise exceptional service and not red flags to a wider malaise. This is plainly self-serving nonsense and a betrayal of their responsibility to the public. I suspect they actually believe it.

The Howard government in 2007 had been aggressively pursuing their marketplace solutions for aged care and talking up the Australian aged care system after the 2006 rape scandal claiming that these were isolated instances and downplaying any suggestion that they were red flags.

Aged Care Crisis (ACC) were getting feedback on what was happening in the system. They made a submission in this regard and were interviewed by the Senate Standing Committee on legal and constitutional affairs. What they were seeing differed radically from what was being said by government. While the interview with the committee was wide ranging and you can link to it, part of the focus was on staffing and on the mandated staffing levels that ACC wanted. Below are extracts from ACC members' comments to the committee in reply to questions.

"... As the demand for aged-care services and facilities has increased exponentially, governments generally have been happy to support the proliferation of private for-profit ventures in order to satisfy that growing demand. Our concern at Aged Care Crisis is that the rights and entitlements of those vulnerable individuals who require those services should not be displaced, diluted or, indeed, seen as a secondary consideration to the primary demands and interests of the corporate sector and their shareholders.

"... At a time when the care needs of residents are higher than they have ever been, with many requiring 24-hour nursing care, we find that facilities across the country have reduced staffing levels generally, cut the numbers of trained professionals and asked nurses to reclassify as personal care attendants. There is no registration system for aged-care workers and no minimum staffing requirements.

"... We must rely on the governments of Australia to protect the vulnerable individuals against abuse, neglect and exploitation in circumstances where the vagaries of market forces have the potential to dictate what level of care and services will be provided to the aged in aged-care facilities.

"... - - - we believe there should be a full review and reform of this Act (Aged Care Act 1997).

"... The current view is that facilities need flexibility with staffing, but our view is that this flexibility is a dangerous policy and can lead to gross neglect of some residents. ------- (when contrasted with child care) we are so cavalier in our approach.

"... The main place that you can cut costs is with staffing. It is a high-staffing, high-human industry sector. As I mentioned in my statement, 79 per cent of the costs in aged-care facilities are for staffing, so they are always trying to cut costs there.

"... - - - It is the low level of staffing which concerns us most. This is a sector that requires good people to give good care.

Source: Standing Committee on legal and constitutional affairs - 04/06/2007 - Older people and the law

We can look back on that interview and look to see where aged care has gone since as revealed on this website. In 2007 ACC were talking about 79% of costs going to staffing. FPCompanyG listed in late 2014. Its first report to the market on 20th February 2015, a few months after it listed, was reported in The Age.

FPCompanyG boasts that it has decreased its staff costs from 63.5% a few months ago to 60.5%. That would include all their staff not just nursing care. At the same time it has increased the number of high care residents - who presumably (by 'improving efficiency') don't need as many staff to care for them!  Once you believe and have no doubts, then everything else that suits you becomes believable.

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The Age Well Campaign

NACA (National Aged Care Alliance) working with the seniors group COTA, recruited a large number of providers to promote its Age Well Campaign in glowing terms with many jumping on the band wagon and talking it up. Many of us were very skeptical because it came from NACA and instead of being debated and discussed, was marketed aggressively.

Contrasting views about the 'Age Well Campaign'

What sort of ridiculous person could challenge what is here, when it is presented so encouragingly by NACA members including COTA's Ixxx Yxxxxx who was speaking for seniors like me to the National Press Club in a program called The aged care time bomb is ticking, and so proudly supported by large numbers of major organisations including the not-for-profits.  It was a marketing exercise and not the discussion that was needed.

In contrast, its critics saw it as more of the same. Another flawed government program justified by the 2011 Productivity Commission's Report, which had ignored the critical concerns we had raised on behalf of 'consumers'.   It was another strategy to build credibility and sidestep critics.

In our submissions to the PC, we had stressed the elderly's vulnerability in the marketplace. We saw this as simply a strategy to further progress government's plans to corporatise the marketplace without alarming us and so give the big corporations more profit at our expense, without providing us with any transparency as to where our money was going.

There were better, safer and cheaper ways of supporting aged care - other than the pursuit of ideological objectives and money for corporate mates who supported the ideology - and at our expense.

We know that we are going to have to pay for aged care but we don't see why we should give the industry a blank cheque.

We don't see why we should sit by while government chooses a more costly way of doing so, one which creates additional risks for us and for the aged care system.

It's the way money is being collected, the way it is being spent, the hyperbole and the bogus marketing to get it past the public that is so concerning.

The Combined Pensioners & Superannuants Association (CPSA) which represents all the Australian battlers who would be selling their homes, an enormous emotional wrench for the people who would suffer most, was particularly critical. It had refused to be bound by NACA's gagging clause and had resigned from the group. CPSA felt there were better and fairer options. They attacked the NACA process and indicated:

"... Combined Pensioners and Superannuants Association warns people to not be fooled by the Age Well Campaign, which should be rechristened the Lose Your Home Campaign," said Policy Coordinator Paul Versteege.

- - - (NACA) has the interests of aged care providers and their profitability at heart. It has a small number of small consumer organisations as members, which are bound by National Aged Care Alliance policy

Source: Pensioners warned: Age Well Campaign = Lose Your Home Campaign - CPSA (30 Jan 2012)

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Government and LASA ignore disturbing allegations

On the 16th of February 2015, The Australian newspaper started publishing a series of startling allegations about care in a nursing home in Bundaberg including that it had planned and executed a cover up. Management flatly denied much of this. Whistleblowers and The Australian were threatened by lawyers.

One of the management team from the nursing home, was so disgusted by this that on the 21st February he spoke up and claimed that management had carefully planned a cover up strategy. Nurses were writing letters to the press telling them that what was disclosed was also occurring in other facilities in the region. This sorry story is analysed on another page.

Turning a blind eye to reports of failures in aged care

At the same time, Txxxxx Cxxx from LASA, the body claiming to represent both for-profit and not for profit aged care providers was speaking to a LASA meeting in Victoria a week later.

Leading Age Services Victoria chief Txxxxx Cxxx yesterday said the sector had "undersold ourselves" for 30 years and now needed to raise its policy and political profile.

And after getting the message out to professionals, it must ensure the community understood the issues.

This is one of Australia's fastest growing industries because we have an ageing population.

Source: Aged care facing a mighty challenge - The Border Mail, 23 Feb 2015

While the industry boosts its image and talks up the challenges for the future in order to get more money (without accountability), it is blind to the crisis that it is really facing - a crisis of care and the perception that this is because they are funnelling money off to fuel their marketplace strategies.

The allegations about the facility in Bundaberg were not mentioned in the report that the community read above. They never talk about things like this.

On the same day, 23 Feb 2015, Linda Mottram was interviewing Senator Fifield on 702 ABC Sydney's morning program. She drew attention to the allegations of neglect and abuse in the Bundaberg nursing home. After that she played back concerns expressed by Lynda Saltarelli from Aged Care Crisis (ACC) in an interview the day before. She was talking about the consequences of understaffing and deskilling, and how market pressures were reducing staff. She expressed once again ACC's concern that there were no mandatory staffing levels of any sort.

As you will see if you visit the linked page, Mottram pressed and pressed and the minister weaved and weaved without answering her questions. I think that Mottram was good - but she missed a crucial opportunity to switch to the failure of any requirement that facilities actually disclose what their numbers and their skill levels are at any particular time. At least other countries disclose their staffing levels and make an attempt to look at this.

Staffing levels and even more importantly the number of trained nurses is an issue that industry and politicians avoid addressing at any cost. In spite of the rhetoric, both show themselves, by their actions or lack of them, to be far more focussed on costs than on care. They will not discuss this issue openly with the public who are concerned about care and this is because their position is not sustainable.

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Seniors vs other seniors and geriatricians

A press report on Channel 9 on 14 Nov 2014 described progress in the proposed trade agreement under negotiation between Australia and China. They claimed that aged care and health would be among the sectors to benefit most - boasting that it would "create future wealth for Australia". Interestingly, it was not the minister or an industry representative, but Ixxx Yxxxxx from COTA, a seniors community organisation, who told citizens about Australia's aged care expertise and the opportunities.

COTA is the organisation claiming to represent seniors that cooperates with the industry on the National Aged Care Alliance (NACA). COTA, with many fewer members than National Seniors, works closely with government and is involved in supporting and assisting in almost all of its aged care projects. It gets media coverage and government contracts to run activities.

A group representing pensioners is very critical portraying COTA as the government's 'lapdog'. The unhappiness and stand offs between groups representing older Australians and the problems in NACA, which caused other senior groups to withdraw, are examined on the later web page "Controlling information" in the "Keeping it all in the family" section. The contrasting views on this page are reflected within the senior's organisations themselves.

In this interview, the seniors spokesman is enthusiastically promoting the prospects for aged care providers in China and the governments success in achieving this. What this has to do with the seniors COTA claims to represent is not clear:

Ixxx Yxxxxx (COTA): "... What Australia offers is firstly how to maintain a high level of standards in aged care and secondly how to go about it in a variety of different ways rather than just one model ..."

Source: Aged care breakthrough following China trade - - 6pm Nine News, 12 Nov 2014  (This video clip and transcript is no longer available)

If you go looking, there is information for the industry.

  • The governments Austrade  web page Aged Care to China: Trends and Opportunities indicates where the opportunities for aged care providers lie.
    The Australian government factsheet on the China-Australia free trade agreement states that this will allow “Australian medical service suppliers to establish wholly Australian-owned profit-making aged care institutions in China with no geographical restrictions”.
  • In November 2015 the Health minister visited China and Indonesia to meet with officials and smooth the way for health and aged care
  • The industry advisory group Ansell Strategic’s paper In a Nutshell: Aged Care Investment in China December 2015 analyses the opportunities. It indicates that “Australia-China International Aged Care Summit was held on 16-17 November 2015. The Summit saw 600 participants coming from Chinese government, peak bodies and institutions and almost 150 delegates from Australia representing 75 organisations”.

Are we selling the Chinese a failed aged care solution?

Others, including the much larger seniors group National Seniors, pensioner organisations, doctors and academics have been highly critical of the system that our government is selling to China.

"... Oh, look, I think there's no doubt the current aged care system is broken. It reflects a decade of inaction ..."

What they've seen, for example, since 2004 is five separate inquiries by government, but no action coming out of it. All of them put on the bookshelf at the end of the day to gather dust.

Source: Aged care under strain - Mxxxxxl O'Xxxxl from National Seniors (ABC 7.30 Report, 14 Sep 2010)

THE Australian health and aged care systems are fatally flawed, with no solution in sight.

Residential aged care is often plagued by accusations of poor clinical decisions and poor management, particularly around behavioural problems, pain management and palliative care.

Successive governments of both political persuasions have failed to make the real hard and courageous decisions needed to address the ageing of the population and to deal with our current structural problems.

Source: Aged failings MJA Insight 2 Jun 2014 by Dr L Mykota (experienced geriatrician) see also radio interview Aged care is "fatally flawed" (ABC Radio - Ian Henschke, 8 Sep 2014)

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Accreditation: Making the industry look good - but others disagree

Here is another example expressing the views of the new Aged Care Quality Agency, which is really the old Aged Care Accreditation Agency, transferred to the federal Department of Social Services and then in October 2015 back to the Department of Health.

Is the Aged Care Accreditation process simply a marketing strategy?

Example: LASA is the body claiming to represent for-profit and not-for-profit aged care providers. The new Aged Care Quality Agency is doing the rounds of provider organisations reinforcing their, and politicians', perceptions of the improvements in care they have attained over the years. They are telling this LASA audience what they want to hear, so they will accept it uncritically. The figures below are from a presentation to LASA by the General Manager of Accreditation at the new Quality Agency. The CEO of the new Quality Agency was LASA's CEO a year ago.


Source: General Manager, Ross Bushrod's (Accreditation Agency) presentation to LASA Queensland, May 2014 (Slide no. 13)

This is certainly not the impression that those of us who listen to the rumblings, and the ongoing adverse reports, get. We take note of what people who have experienced the system are saying and the assessments made by more objective organisations like universities. The Age reported on a study of staffing undertaken by academics in Victoria in 2009.

AGED care has deteriorated in Victoria over the past two years, with some nurses looking after 47 elderly people at a time at nursing homes, compared to 39 in 2007.

The surveys, by Melbourne University, found that in 2007, (staffing) ratios ranged between one to six and one to 39, at worst, at Victorian facilities. This year, the ratios ranged between one to nine and one to 47.

Source: Aged care goes from bad to worse The Age 30 Nov 2009

In 2011, another nurse academic at Latrobe University expressed her concerns about the adverse impact of the care provided by untrained staff since 1997 in nursing homes in Australia. She described the progression of aged care from the provision of care by untrained convicts in the early colonial days to trained nurses in the 19th and then 20th centuries - with a regression to untrained aids starting in 1997 just before the beginning of the 21st.

She indicates that "aged care is going backwards" and that "registered nurses are becoming 'a scarce commodity' in the aged care industry".

The aged today are largely cared for by untrained staff, with supervision from a Registered or Enrolled nurse. The role of the Registered Nurse is onerous where they could be responsible for up to and more than 60 residents in a shift.

Despite regulation and inspections by the Department of Health and Ageing, we are continuing to hear of mistreatment of the aged in Residential Aged care Facilities, which shows that not much has changed in the history of the sector.

Unfortunately in these early days of our colony there were those in the community who believed that untrained staff were sufficient to care for the elderly. Is it any different today?

The needs of the elderly in our facilities are becoming more and more complex. Even this is not enough for Governments to identify the need for more Registered Nurses in Aged Care.

Source: Aged care and untrained staff - Dr Jean Booth, La Trobe University (18 Oct 2011)

Criticism of accreditation in aged care

The accreditation results in Australia as revealed in departmental documents, in their reports and in their magazine have steadily improved over the years with the number meeting all 44 standards increasing from 64% in 2000 to 95% in 2012. But the figures they are reporting are deceptive.

They are not the total number who failed in the year, only the number who had not yet corrected problems and been re-accredited at the time the agency reported to government on 30th June each year.

When the figures were challenged in 2008 it turned out that 7% and not 1.8% of homes had actually not met all standards over the year. But that said, the rate of successfully meeting all standards has increased over the years. These findings contrasts with the information coming out of the community, various academic research and journals, and being published in the press.

Many are critical and distrustful of the Accreditation Agency. In December 2008, Aged Care Crisis discovered that the Accreditation Agency reported its results selectively in order to give a positive impression. The qualification "as at last audit" in the presentation above, rather than giving an annual number or percentage of failures per year, suggests that they are still doing so in their presentations.

The number per year or better still a bar graph representing the failures per year is the more usual and more accurate way of presenting figures and comparing them.  In 2015 the Agency was still presenting its results to LASA in the same way.

These figures are the *three-yearly accreditation reviews, for which each home has months to prepare. They don't represent what happens for the remainder of the 3 years. Also, the Agency does not actually measure outcomes so there are reasons, other than improved standards of care, why the Agency's figures might have improved. These include that providers and their staff are now aware of what they need to say and do, so the process has become routinised.

*The Budget 2015 announced a raft of measures - including a reduction in audits (eg, site audits reduced from once every 3 years to five years) and plans to privatise provision of accreditation services, allowing providers to choose their own agency to accredit their facility.

The results don't reflect what is actually happening on a day-to-day basis, and because they don't look at the actual results of care and probably never have.

There have been recurrent  allegations that the process has been "gamed", with providers bringing in teams with extra staff and equipment just prior to the accreditation inspections. There is no information to indicate how common "gaming" is. Documents released under freedom of information in December 2014 "show that almost one-in-five new nursing homes failed to meet quality standards last financial year". This undoubtedly reflects a learning curve but whether that is in improving standards, or learning how to game the system, is debatable.

Nutrition and accreditation: A thesis study of nutrition in aged care facilities from Monash University in 2013 shows that 64% of aged care participants were undernourished and this had significant adverse consequences for health, for quality of life and for mortality.

The study gave the reasons and found that accreditation standards had failed to address the problems. Nutritional status like other markers of real care are not measured in aged care. The argument critics make is that this finding is very probably representative of what happens with accreditation because it does not measure anything real.

Accreditation standards are meant to ensure quality of care but in this study, they failed to sufficiently ensure a high standard of nutrition. A number of factors were found to explain this, including lack of prescriptive standards, poor staff knowledge and attitudes, very stringent budgetary constraints, and a general failure to perceive the importance of nutrition as a part of clinical care.

Source: Nutritional status and its consequences in low level aged care: implications for aged care accreditation standards and guidance - Monash University - Thesis 2013

A nutritionist doing a doctorate in Queensland was inspired to do this because of the malnourishment that she saw in Australian nursing homes.

Ms Abbey said she is inspired by her own experiences of poor nutrition in residential aged care.

"I have gone into a number of frail aged facilities and seen so many residents who are malnourished or teetering on the edge of malnutrition," she said.

Source: Pioneering nutrition study Australian - Australian Ageing Agenda (18 Mar 2010)

External reviews of the Accreditation (Quality) Agency

An outside review of the accreditation process in 2002 identified the agencies failure to collect the sort of data that would allow it to assess its own effectiveness.  It made a number of other criticisms that have been repeated over the years. The agency agreed to collect data but never did so. Instead it commissioned another organisation that embraced the same patterns of belief to review it and give it a pat on the back in 2007. This review agreed that it was 'not necessary' to monitor actual outcomes.

Another review was undertaken in 2009 to which submissions were invited. Many of us made submissions but if a report ever resulted from that, then it and the submissions were not made publicly available. Some of us wanted to see that overdue report before making final submissions to the 2010/11 Productivity Commission inquiry into aged care. We complained, but that did not help!

As recorded above, we have academics in Victoria and Queensland making criticisms about nutrition and staffing. There have been press reports describing allegations about the quality of food in Canberra as well.  Below on this page, academics from NSW and from South Australia are even more critical. While the focus is different, each is describing deficiencies in care.  But the accreditation process does not record them or their incidence.  They don't look.

Perhaps we should let someone from the community say what they think of the care being provided in our nursing homes. This was the response on a comment page reporting on FPCompanyG's plan to float on the stock exchange. Obviously the person wanted the view known. I have taken the liberty of printing it here without the name. It's the sort of thing that is coming from those who see what is happening in the nursing homes. The accreditation agency does not see these things.  Is that because it lives in a different world and just doesn't have the same view as the families.

"... I have a close relative in a FPCompanyG facility and my observation on regular, monthly visits over the past 3 years on the statement "the business had grown by offering premium services, optimising government funding entitlements and delivering efficiencies." is a load of rubbish.

The service is definitely not "premium" because the "efficiencies" have been gained by being constantly short of essential items such as catheters and continence pads, by serving boring, repetitive, low quality food and by never having sufficient staff.

Floating on the stock market will surely exacerbate these problems as shareholders wring their profits from the poor old buggers warehoused and waiting to die.

Source: Response to Second aged care provider prepares to float on ASX - Australian Ageing Agenda (24 Sep 2014)

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Criticism of aged care over the years

There is an ongoing and steady flow of information coming from those who see what is actually happening and this contradicts what we are being told by the providers and by the agency responsible for monitoring standards of care.

The agency's conduct in its handling of data goes to its credibility as a regulator. Provider's willingness to hide information and fire those who disclose failures in care goes to their integrity.

What people are saying

There are some strong differences of opinion in the community about the direction in which governments are taking aged care. More importantly, they don't trust politicians and feel out of touch with what is happening because information is being concealed. They don't believe what they are being told, and are unable to contribute and have their voice heard.

Instead of pumping money into creating a health system, and in particular an aged care system, which can cope with an influx of high-care patients, the government has demonised the ageing process.

It has made cuts to and put tough conditions on pensions, disability pensions, carers' allowances and aged care funding, and it intends to force the retirement age up over the next few years.

While these measures may save money in the very short term, in the middle and long term they are going to be an absolute disaster.

Source: Government on wrong tack in aged care - The Camden Advertiser, 17 Sep 2014

The last 6 years: Here is some of what people have been saying over the last 6 years. They tell us where it is going wrong. In some instances I refer to reports that were mentioned on the page 19 years of care but in only a few have I quoted from them there. Any links not given here are on that page.

2009: Acting Secretary of the Victorian branch of the ANF, Yvonne Chaperon, said the results proved there was a crisis in aged care:

She said the Government must increase wages for aged care nurses, who earn about $300 a week less than nurses in hospitals.

The Government should also introduce minimum nurse-to-patient ratios for every aged care facility in Australia because they currently only applied to public facilities, she said.

Source: Aged care goes from bad to worse - The Age, 30 Nov 2009

2010: In May there were accounts of poor care and neglect uncovered by an undercover journalist in homes owned by two of our major providers of care. Then it emerged that these companies had problems in multiple other facilities and in one case globally. In all of these instances it was about staffing and management. There is more about this on 19 years of care.

Mxxxxxl O'Xxxxl from National Seniors was clearly aware of the problems that the members of his organisation were facing. National Seniors commissioned Access Economics to report. O'Xxxxl's comments based on that report tell us what was happening and the number of media he spoke to tell us of his concern:

If you look at some of the detail of these cases, a lot of them are around the adequacy of the care being delivered, and breaking that down further, it comes very much back to resourcing levels, to staffing levels and then within staffing levels the number of registered nurses, the qualifications of the staff there.

Source: Aged care under strain ABC - The 7.30 Report, 14 Sep 2010

"They're waiting longer and longer for help - either in nursing home beds or at home - that just isn't there. This situation is unacceptable in a country as advanced and as wealthy as Australia."

Source: Aged-care reform needed urgently: report AAP Sydney Morning Herald, 15 Sep 2010

Mr O'Xxxxl says there has been a decade of inaction on aged care. "It hasn't arisen overnight this problem. It's been there and governments have tended to push it away and ignore it, hoping it will go away and instead we've now got a situation where we've got a system that's unsustainable," he said.

Source: Aged care in crisis, report finds - ABC News, 15 Sep 2010

Joanne Bryant, an enrolled nurse in her submission to the Productivity Commission, described her experiences returning to nursing in aged care after 17 years as "like being transported to another planet", and being horrified at the lack of staff.

2011: In 2011 we had the Quakers Hill fire which revealed the type of person that some nursing homes were employing and the way warnings by staff were ignored. I dealt with this on the "19 years of care" web page.

2012: On the 7th September 2012, Glen Rees CEO of Alzheimer's Australia wrote to Lynda O'Grady about the findings of their report Consumer Engagement in the Aged Care Reform Process, which looked at the stories of over 1,000 consumers who attended consultations. They found:

"... Consumers had serious concerns about the quality of services provided within residential aged care facilities including concerns about staffing, use of restraints, inappropriate environments, and reduced mobility due to lack of opportunity for physical activity ..."

Rees went on to refer to the "increasing concern about the inappropriate use of antipsychotic medication" . He pointed to the recent Lateline program about medication "to get a sense of the frustration that consumers feel with the quality of residential care". This he indicated, was only one "example of the poor quality of care individuals with dementia are receiving as a result of services in which staff are not adequately trained, supported or resourced to provide quality dementia care including responding appropriately to behavioural and psychological symptoms of dementia".

2013: By 2013 any improvements after the 2010 disclosures had gone. There were a whole series of disclosures of poor care and failures in oversight on Lateline, in The Age and in Womens' Weekly. There are links to all these on the page "19 years of care" The comments below suggest that care was particularly bad in Canberra.

"...  Frail and elderly people are being put at risk of falls, dehydration and malnutrition in ACT nursing homes due to a lack of mandatory staff-to-patient ratios, advocacy groups for the aged have warned.

Source: Low staffing levels in ACT nursing homes put elderly at risk Sydney Morning Herald September 13, 2014

A Canberra woman has opened up about her despair over her elderly mother's treatment at a Canberra nursing home, revealing dinner some nights was just two party pies and a banana.

Source: Anger at quality of Canberra nursing home food, hygiene - Canberra Times, 13 Sep 2014

A Study by University of NSW: The Aged Care Funding Instrument (ACFI) was intended as a means of linking funding to better care of residents, including demented patients by measuring quality and so improving care. As the article below indicted "one of the most pressing issues that the Australian Government and the aged care industry face: that is having a reliable regular assessment mechanism for ensuring the provision of quality residential aged care services."

Many of us think that has been a glaringly obvious problem that no one has wanted to look at for the last 19 years so it is encouraging that someone else is saying it.

The report of a study done for the government by researchers at the University of NSW looking at this issue was released in January 2013. It is of interest, not because it showed that this instrument had resulted only in a slight improvement, but because of the reasons for that and what it revealed about the care that was being provided and the attitudes of staff.

One of the main things the study assessed was the care plans for residents with dementia. They found there was a "culture of poor care planning practice". "Overall care plan quality remained low, with none of the care plans fully addressing residents' care needs associated with BPSD" (behavioural and psychological symptoms of dementia) following the intervention.

"Care plan quality remained low with between 31% and 65% of care plans still not addressing current behaviours" and "the care needs of residents with BPSD are not well assessed and documented in care plans" There was little evidence that the policies adopted by facilities "were put into practice".

It seems that the program lacked credibility, and the culture of the facilities where the staff who actually gave the care "were often removed from using care plans and the ACFI results in their care". Even in the one facility where they were made available to staff "it was found that most staff did not read them".

On average, assessments were 12 to 15 months out of date and the assessments done by the researchers revealed that there was a large discrepancy between what the researchers found and that in the plans. "Scores (that) did not accurately reflect resident current behavioural status". This is what care was supposed to be based on.

These comments are based on the Summary of the report and on an article published in the Internet Journal of Psychiatry Volume 3 Number 1

2014: In September 2014 there was the very revealing and confronting ABC program Death in a five star nursing home that I wrote about on the web page "19 years of care". Then another report from Canberra.

They said they would shower her every second day but it was more like once a week. She smelled so bad sometimes I nearly vomited

Source: Anger at quality of Canberra nursing home food, hygiene - Canberra Times, 13 Sep 2014

In an excellent article, a professor of nursing describes the many problems and the parlous state of many of our aged care facilities. She is particularly critical of the lack of interdisciplinary staffing and collaboration and she compared this with Holland where care was very different.

In Korea we say "it’s like pouring water in a cracked jar", when describing a helpless and hopeless situation where all the efforts and investments are lost because there is an unresolved fundamental problem. New policies and reforms targeting aged care workforce and care quality issues often remind me of this proverb

We also need practitioners from across the disciplines, who can contribute specialist expertise. Then, perhaps, we can mend those cracks in the jar before we continue pouring water in it.

Source: Breaking down professional barriers in aged care Australian Ageing Agenda on February 11, 2014 in Opinion

There are many critical comments to the article and many nurses do not agree with her solution. Although neither the author not the critics mention it, my assessment of this article and the comments, is that underlying all this is a working environment whose ethos does not attract either nurses or other professionals. Its an environment where they don’t feel welcome or that they are making a useful contribution or can make a difference. In my view that is an issue that too often relates to the commercial way the nursing homes are managed and the culture that results.

2015: And 2015 did not get off to a good start either.

"The severe shortage of qualified doctors and nurses to provide specialist palliative care services to dying residents of aged care facilities in NSW is a widespread problem," he said.

"It can be shown that their services can significantly reduce both costs and, more importantly, suffering."

Mr Bxxxx said proper palliative care services providers allow adequate at-home care, but also "consult, advise, support, liaise and provide treatment in relation to dying members of the NSW community in other environments, particularly in aged care facilities and in acute hospitals".

Source: Patient care needs repair, says Cancer Council NSW - Northern Star, 27 Jan 2015

But it’s the cuts to the hours of care provided at Txxxxx Gardens in Fyyyyy that has seen it described as a “disaster waiting in the wings” by the union representing nurses.

Australian Nursing and Midwifery Federation NT branch secretary Yxxxxx Fxxxx said cuts of about 130 hours per month had compromised the standard of care at Txxxxx Gardens in Fyyyyy.

“It’s a disaster waiting in the wings,” she said.

“The staff are distressed about the care and treatment of residents ... with constant cuts they feel they are unable to provide the level of care needed.”

“We have situations where if staff speak out they face being targeted ... including hours being cut,” she said.

Source: Palmerston nursing home cuts jam rations and staffing hours to save money NT News 4 Aug 2015

The feedback group Care Opinion Australia is also critical about what is happening and this is a response to the exposures of issues in NFPCompanyE's Queensland nursing homes.

Care Opinion Australia chief executive Michael Greco said the issues could be addressed through better communication between providers, residents and their families.

"... I don't think we have a culture out there in the services where they are welcoming feedback," he said.

"... People tend to be quite fearful of any feedback. The public aren't, they want to give the feedback but they want to make sure it's heard and they want to make sure it's listened to and acted upon."

" - - - if there's a whiff of something that's not quite right, then we need to hear that immediately so we can prevent anything escalating".

Source: Aged care advocacy group Care Opinion Australia urges more nursing home industry transparency - ABC News, 18 Mar 2015

The complaints about food continue and this is confirmed by repeated studies.  But food costs money and when reducing costs is a major objective, then food is going to be the first target - especially when the people eating it are not in a position to complain.  It is accepted that there are "high rates of malnutrition". 

Accredited practising dietician, Cherie Hugo founded The Lantern Project when Cherie discovered an urgent need for change when she was working in aged care.

“Between 50–80% of aged care residents in Australia are malnourished, and the community needs to work together to find a tangible solution,” she said.

Source: Dietician to speak about healthy food for older Australians mysunshinecoast.com.au 20 Jul 2015

Aged care residents on average consume just one serve of dairy per day, falling well short of the recommended four serves necessary for adequate protein and calcium intake, according to the results of a new study.

 - - less than a quarter of residents met the recommended intake for dairy, pointing to the need for greater awareness and education among food service staff.

Dr Iuliano said dairy was a versatile and relatively cheap food group and was also appropriate for residents on a texture modified diet, and therefore had an important role to play in alleviating high rates of malnutrition found in aged care.

“Ensuring adequate dairy serves are available on menus at aged care facilities will reduce malnutrition, and potentially the comorbidities and cost associated with malnutrition,” she said.

a large randomised trial which is aiming to reduce the fracture risk among aged care residents by 30 per cent by increasing dairy intake.

Source: Study highlights low dairy intake among residents Australian Ageing Agenda 29 May 2015

A PALMERSTON nursing home is so desperate to save a bit of cash it is limiting residents to one jam sachet daily and, to make sure there’s no double dippers, staff are forced to count the sachets daily.

The union representing patient care assistant and catering staff at the Txxxxx Gardens, United Voice, said a change in the roster meant residents were no longer offered a choice in meals.

“If it’s fish for dinner and you don’t like fish, well then that’s too bad,” United Voice acting branch secretary Erina Early said.

She said resident were often given baked beans for dinner.

Source: Palmerston nursing home cuts jam rations and staffing hours to save money NT News 4 Aug 2015

Someone commenting on an article on Australian Ageing Agenda:

I worked as an agency worker for many years and the things I saw in nursing homes will haunt me forever

Source: Frontline workers can help clients achieve adequate food intake Australian Ageing Agenda 23 Aug 2015

There are allegations that nurses do not have time to take residents to the toilet so instruct them to use an incontinence pad.  This is quicker to deal with. It is suggested that in many nursing homes, incontinence pads are rationed. 

Nurses are forced to leave residents in soiled pads for long periods increasing the risk of urinary tract infections and infected pressure sores. 

The allegation by a nurse writing to a newspaper after serious allegations in Queensland homes including about continence management is revealing.  She claimed that the problems found were widespread in Queensland homes.

At another Bundaberg aged care facility, carers were told to turn incontinence aids around so the "wet" bit went to the back. That ensured "maximum fill".

Aged care is a harsh environment to live and to work in. People want profit.

The current ratio of care is also geared to minimal cost.

At one facility where I worked, we had wound care kits that were essentially tackle boxes with some normal saline, cotton gauze and bandages. For complex wounds, we were told "it's basic bush nursing" and we had to do what we could with what we had.

Source: LETTER: Aged care is a business - Central Queensland News, 19 Feb 2015

A nurse commenting on a letter to the press by another nurse:

I would rather jump off a bridge than get old in this country. I have seen it all. Don't tell me to make a complaint, I am still trying to pay off my home.

Source: LETTER: Aged care is a business Comment on this letter - Central Queensland News, 19 Feb 2015

A mother describing what she saw and the problems she had when she was forced to put her disabled daughter into a nursing home:

Through visiting her daily, I now know three things: an independent inquiry into aged care is essential; young people don't belong in such places; and that such places are the best argument for legalising euthanasia.

I have seen appalling behaviour from staff but am called a troublemaker when I try to stand up for decent care.

Source: Heaven help residents 5th letter to The Age, 14 Nov 2015

A nurse giving evidence to a Coroners Inquest into the death of a resident whom no one had checked on:

Ms Sxxxxxxxo  said she thought none of the residents "received the care they paid for" and that she would not put a relative into the aged care facility.

She said she had complained to her management about understaffing, describing it as "unsafe" but was told there would be no change.

Source: Hobart 85yo nursing home resident died with head stuck between bed and pole: inquest ABC News 14 December 2015

2016: On the Scandal after Scandal web page there is a list of 34 articles, between January the end of July 2016, complaining about large profits and poor care, assaults, malnutrition, medication failures, staffing issues, dental care and much more.  It seems to get worse as the years go by.

- - - "More choice and more options to pay" mean nothing when there is not enough staff and not nearly enough registered nurses on the job

- - (From a GP) - - I have seen countless examples of poor care in "luxurious" homes.

- - - low staffing levels is compounded by added stress on the registered nurse in charge - - - is driving away experienced nurses,

- - - questions as to why aged care is sliding as profits for operators soar?

Source: From Several separate letters to the editor The Age 5 Jan 2016

And then there are these are comments from nurses who spoke out about a nursing home in Queensland:

"Staff are not turning up for work and some are having breakdowns. Residents are not being cleaned properly and too many have tinea between their toes, which smells.” She said a facility manager, who had tried to improve the situation, had resigned last week.

This used to be such a lovely place. We were all like family. Now residents are just numbers.” The nurse said incident reports disappeared and the facility had lost too many experienced registered nurses (RNs).

“Night shifts were terrible,” she said. “There are 181 beds and only one RN on at night in the whole facility with six AINs. We had quite a few gentlemen on catheters and their penises became inflamed and infected because they weren’t cleaned often enough. Residents weren’t always showered.

I was the only one on duty and did not have a clue as to what my role was and I was given no support at all. I should have made a complaint to someone higher but I was afraid that I would rock boats and get fired.”

Source: Residents ‘neglected’ Gold Coast Sun 15 June 2016

The key problems that emerges over and over again, year after year, from resident's families, from whistleblowers and from investigations are:

  1. nursing care - not enough staff (particularly well trained staff), a mal-distribution of skills, diversion of care staff to administrative work instead of nursing, that the nurses are not adequately trained for the tasks they undertake, and that they lack the motivation required to engage with the processes.
  2. a culture in management - that is prepared to tolerate poor care, to deny that it is poor, to find excuses and justifications for failures instead of addressing them, that disregards and belittles the residents and their families and pursues anyone who tries to speak out. Feedback and criticism is seen as a threat.

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Contrasting solutions

Some have a very different approach to the way social services including aged care should be provided.

Different views about government and the market

On this and related web pages, I have given multiple quotes and examples of government and industry thinking. These illustrate the determination to use markets as the medium for providing aged care. The response to failures has been to resort to more regulations and to ever more complex processes in an attempt to make this work.

This was the response to the attempts by government to stop the excessive fees to individuals that were boosting profits and the rorting of taxpayer funding for the market. These are the consequences of providing public services through the free market and in vulnerable sectors.

It also illustrates the extent to which ACSA, the organisation representing not-for-profits has identified with and uncritically accepted the market solution to the problems of ageing. It shows a government reacting to the consequences of its own policies. The thinking is deeply embedded and goes unchallenged.

"On one hand, the government is encouraging a shift to a consumer-led and market-based system, but on the other hand its ongoing regulatory intervention when providers try to move in this direction is stifling investment and eroding business confidence," said Sxxx Rxxxxx, CEO of Leading Age Services Australia.

"Government is applying a broad-brush legislative approach, which is inconsistent with market-based principles," Mr Rxxxxx said.

Pxx Sxxxx, CEO of Aged & Community Services Australia, said the department appeared to be attempting to restrict how providers and consumers negotiate payment arrangements for additional services.

Source: Department’s guidance on aged care fees prompts criticism from providers, investors Australian Ageing Agenda 16 September 2016

Another problem is that citizens expect government to fix problems and don’t see that they have any role in this.  Yet every time government looks the other way or trusts the industry, they betray that trust and exploit any loopholes they can find in the system.  My argument is that government alone does not have the capacity to deal with the problems created by competitive markets in vulnerable sectors.

The UK has been down this path.  Not only has the market failed to provide the vulnerable with a reasonable quality of life, but government's attempts to regulate and set up structures and processes for providing care have often compounded the problems.

A number of thinkers and researchers have been looking at this and have come to look at a very different way forward. They see lives as lived social experiences and place these social interactions and relationships at the centre of their thinking. They look at the manner in which markets and governments currently both impede rather than support this. They have persuaded the UK government to have an inquiry to look at these issues. I give some quotes and links here, but there is extensive literature:

Even more fundamentally our society is failing to value and respect the positive role played by families, disabled people and older people in our society - - - we treat care as if it were a commodity to be rationed and controlled by a bureaucratic system. The result is devastating: - -

The Centre for Welfare Reform, with its partners in the Rethinking Care Project - - (suggests that) -- the system of social care in the UK is based on fundamentally flawed assumptions.

The social care system is in the midst of a crisis that is conceptual, political and economic. We have lost touch with the true meaning of care and replaced it with the idea of a standardised service, controlled and regulated from above.

A dangerous culture of compliance has replaced trust and common-sense with bureaucracy and commerce

Source: Centre seeks Parliamentary Inquiry on Social Care Centre for Welfare Reform 13 April 2016

The key to keeping people safe and ensuring people have good lives is not a growth in bureaucracy, but a strengthening of the human relationships of love, acceptance and respect. We are losing perspective and lives are being harmed.

- - - the authors found that communities that had been built on principles of love and community are now forced to fit within damaging regulatory regimes. This is a grave problem and these intentional communities are under threat.

Source: Open Letter on Regulation Centre for Welfare Reform 2015/16

We repeatedly stressed the importance of finding sustainable ways of helping people achieve their expectations by exploring relationships, associations, and community assets – the counterpoint to the general tendency to see solutions as paid for services.

Source: Life Is Not a Commodity Centre for Welfare Reform

- - - he recognizes that it is the breakdown of trust in others which fatally undermines our ambition to help people get good lives.

When governments pretend that they can run markets then we have a recipe for mutual disappointment.

We should not just be thinking about ‘spending our individual budgets’; instead we should be thinking about how financial resources can be linked to relationships, communities and our gifts and capacities.

It begins to feel like we will only be able to reclaim control over our lives and communities if we begin with ourselves.

Source: Much More to Life than Services Centre for Welfare Reform 2011

The proposed Community Aged Care Hub in intended to put community at the centre of aged care and in control. It creates a context within which we can support the "strengthening of the human relationships of love, acceptance and respect" and to channel funding, markets and government support to meet those objectives. Rather than futile attempts to regulate, it will use social pressures, trust and relationships to guide the system. Regulatory effort would be a fallback position but because it would start at the bedside, it would be effective.

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And in hospitals too

Ageism in hospitals: Karen Hitchcock in her interview on 7.30 report on 12 Mar 2015 and in her Quarterly Essay Dear Life - on caring for the elderly in the March 2015 edition, describes the ageism in our hospitals, an ageism which leads older people to consider themselves as a burden on society. The term 'Bedblockers' expresses this well and experts have been critical of its use. The aged are clearly a nuisance in many hospitals.

Others have expressed concern at the pressure to get the aged out of hospital in order to find space for the young.

Dr Bxxxxx says it can put unnecessary pressure on families to find an aged care home place.

"Using the term bed blockers implies that they're a nuisance, that they're blocking beds for other people," she said.

"It's not incumbent on the older person to feel they shouldn't be there."

Source: Aged care expert critical at 'bed blockers' reference for older people ABC News 14 Aug 2015

Example: Exxx Rxxx a retired doctor and a blind nursing home resident was sent to hospital in pain with a fractured spine. She developed diarrhoea and was difficult to nurse. The hostel refused to have her back because they did not have the staff to care for her. An eviction order was read out to her publicly in the ward (she was also partly blind) and she was returned to the hostel. They were unable to cope with her care and her GP had to arrange to admit her to another hospital where she died. 

There was strong criticism of this and the hospital apologised, but the manner in which a formal eviction order was served and then publicly read out in a crowded ward illustrates the administration's pattern of thinking and the pressures being put on staff.

Its clearly not unusual for the elderly to be ejected from hospitals. Beth Wilson writing about this for the Medical Observer commented:

My friend stopped in her tracks (when she was told about the case above) and said: "That’s what happened to my mother in Canberra just last week! The hospital sent her home to a cold, empty house, no supplies, no food, all alone. It’s freezing in Canberra. She’s 89. How can they do that?"

Source: Discharge of elderly in need of urgent review Medical Observer Sept 24, 2015

When it happens in the country, there are additional consequences for those who should be helped. In the example linked to below, a long time resident of a country town was sent off to a nursing home in a distant town instead of being allowed to stay until a bed became available. Locals tried to rescue him but he died alone away from family and friends.

This problem is so common and the consequences for the elderly so distressing, that those country health professionals recently converged on Canberra to lobby for relief.

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Staffing numbers and skills

What has been done to staffing in nursing homes is a constant theme and emerges over and over again in complaints by residents, by staff and by critics who have examined the system.

There is a large amount of international literature linking staffing directly to standards of care. But in Australia, there is no literature because nobody knows how many staff there are in nursing homes. If it is known then, like so many other aspects of the system, we are all being kept in the dark. We can only surmise that there is something to hide. 

It is clear that some nursing homes exploit this loophole in our regulations and the poor standard of oversight provided.  There are some that have no staff at all for long periods of time. 

In 2012, Aged Care Crisis wrote to the minister about a recently accredited nursing home, one with a poor record for care, because no staff at all were rostered on at night - a period of 10.5 hours.  But the department has always been a black hole and little is ever done.

Anyone who knows anything about care has known the critical role that adequate staffing plays - for at least 19 years and realise that it has been a key problem in the sector.

In Australia, every effort to get government to set minimum staffing numbers and standards, or to disclose staffing numbers and skills, has been tenaciously resisted by industry and all governments.

Nowhere is their lack of integrity and lack of accountability to the public more vividly illustrated. They do not deserve our trust if they try to hide things that impact the wellbeing of citizens from us. We should not give it to them until they have earned it.

As a community we need to get in there, see what is happening and try to sort it out. This is much too important to all of us to leave to the self-interest of businessmen and the politicians they control. We should not allow the cost of staffing to become part of their gladiatorial contests. We need to take control of aged care and set the agenda.

Please note: The first four sections of Aged Care Analysis are published and the remaining sections will be made available as soon as possible.

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