19 years of care

Looking back at the decisions

It is interesting that in 1997, Australia was visited by a high profile charismatic and very successful US aged care businessman whose core messages were that you should hand public services to the market to sort out, that there was plenty of fat in the system, and that you did not need expensive skilled nurses in aged care. Bathing and toileting did not require these skills.  Bishop is reported as subsequently expressing and embracing the same sentiments and health minister Wooldridge briefly advocated some of his policies.

Since that time, the percentage of frail high care residents in nursing homes has increased steadily and the average number of RN's employed by nursing homes has halved from more than a third to less than 15%. During this period, the unhappiness about the services provided has steadily grown and a succession of scandals have occurred.

Its as if they were deliberately conspiring with providers by keeping customers and the community in the dark and removing all accountability.  They were throwing the elderly to the wolves.  Its as if the system was set up to be raped.  Many might argue that it has been.  But worse still, several women, some over 90 have been.

Critics warned them that seniors were vulnerable and that there was no effective customer to hold the providers of care accountable. They simply ignored this.

It seems incredible in retrospect, that so many people believed implicitly in what they were doing, believed that a market like this would work, and believed that this was the best way to provide aged care.  I would not have thought it possible if I had not already studied exactly the same thing in non-medical contexts and again in health care in the USA. 

In the USA I spoke with people who had personal experience, and looked through large numbers of internal corporate documents. I was forced to accept that not only management, but thousands of employees believed implicitly in similar but even more bizarre business practices. Thousands of patients suffered.

Exploring these issues: In subsequent pages on this website, I am going to explore why this happens and show that this is a human failing. We are all at risk of creating and then believing in crazy ideas.  It is something which most of us will do in smaller and less harmful ways during our lives. Sometimes it is the only way that we as individuals can function effectively in a complex world. 

We are social animals and we build our ideas and validate them during our interaction with others. In a normal functioning society we are checked and put right by others and no harm results. It is when we as a society fail to do so, that it can get out of hand.  That seems to have happened here.

This is social pathology. To make effective changes we need to recognise that this is a culltural illness,  make a diagnosis of what is happening and understand the pathology.  That diagnosis needs to include the reasons why we are failing to adequately confront and address ideas like this before they get totally out of hand and become our masters.

19 years in a nutshell: The aged care sector has been exposed to the full consequences of these free market decisions for nineteen years. All challenges to what was done then and is still being done now have been ignored. How this has worked, and what the consequences are, is largely hidden from the public.  It is only when an occasional whistleblower speaks out that we get a brief glimpse into what is happening.  This web page documents only some of the more confronting but ever increasing glimpses that we have had into the failures of this system.

Recognising the problem, that this is a sick system, is the first step to a diagnosis and this is what this page does.  If you are not convinced, follow the links.

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The first failures - reviews and missed opportunities

The first scandal, the Riverside scandal in a Victorian facility, erupted in 2000 only 3 years after the 1997 legislation and 18 months after all requirements for staffing were removed and this was left to providers. It was followed soon after by another scandal and other reports of failures in care. There was intense criticism.

This was the beginning of a long process of recurrent scandals and of almost as many inquiries and reviews of the aged care system, many in response to unhappiness in the system. The failures in care and of the accreditation and complaints system received extensive coverage. Many attempts were made to patch the system, but the core problems in the system were never confronted. These were elephants in the room at every inquiry but they were not confronted. Doing so would have meant challenging core beliefs and this was not something that could be done credibly.

Never ending reviews of the system: In 2010 there was once again growing disquiet and some of us were optimistic that the Productivity Commission report was going to be different. I urged people to make submissions and in preparation, I wrote web pages describing 32 of the inquiries that had been done since 1997 to show how each had failed. Sadly, the elephants in the room were not noticed and the report was a damp squid. What eventuated was the Living Longer Living Better 'reforms' which were based on the same unchallenged belief systems. Thanks to that review, we are now 6 years later once again in crisis and we are raising the same issues.

Neglected reviews and missed opportunities: We recently discovered that shortly after Riverside, there was an attempt in Victoria to make useful changes. We only traced one paper from that review, but it reveals that the Labor Government was proposing major changes including full accountability for staffing and many of the changes that Aged Care Crisis and others have been advocating for.

Not long after that in 2001, two academics who examined funding, demographics and access issues, proposed that control and management of aged care services be lodged in local regions and that all decisions about aged care be made there. Although it was still a managed system and the community was not directly involved, its objectives and mode of operation was remarkably similar to the Community Aged Care Hub that we are pressing for. We believe that at that time, it would have worked and we would have a very different system today.

These two reviews provided an early opportunity to address the problems in the system and move in a different direction. There is little evidence of any real interest in this at the time and the opportunity was lost. No review since that time has proposed anything like it.

More information: On the linked page, I explore these matters and the early reviews in more depth. There are links to pages that examine the Riverside and another scandal. I look at my 2010 assessment and provide links. I also look at the two missed chances using quotes from those documents and linking to them.

Learn more: Response to early failures

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The unfolding scandals - press coverage

Since the Riverside scandal, aged care has been characterised by a succession of sometimes startling failures occurring every few years. Instead of seeing them as red flags to serious underlying problems, they have been brushed aside as rare exceptions in an otherwise exemplary system.

But when these are brought together, it is clear that they occur too often.  They are not exceptions, but red flags to a wider and deeper problem. If we look further we find that there are many more less prominently publicised accounts of unhappiness, particularly among staff and families. This unhappiness seems to build up into a wave of criticism. This is accompanied by inquiries and some minor legislative changes. After a few years there are more confronting revelations and unhappiness grows again. This has been happening since 1997.

Previous experience: During the late 1990s and early 2000s I studied the US corporatised aged care system. During this period it was undergoing rapid consolidation and expansion. The corporate for-profit part of the sector was plagued by under-staffing, poor care and extensive fraud. I documented what was happening and wrote about 65 web pages describing the behaviour of all of the large US corporate aged care chains. Many still operate in the same way. I have since watched Australia adopt the same policies and develop similar problems.

2000 to 2006

During the late 1990s, particularly in Victoria, aged care was seen and promoted by the government in Victoria as simply another commercial opportunity. Entrepreneurs were given bed licenses and bought or built small nursing homes. Their interest was primarily commercial and many had little, if any aged care experience. During the early 2000s many of the problems occurred in homes owned by these small companies. Other failures were companies that, like Riverside, were owned by problem owners who managed their own nursing homes.

The rape scandal

Issues of staffing and care continued to fester until the next major red flag in 2006. This was a very confronting scandal in which elderly residents were raped by those who cared for them. Even though other nurses knew this was happening and managers were told, no action was taken. There were long delays before the police became involved. The prime minister and the aged care minister’s claims to another rare exception dissolved when examples of rapes and similar behaviour in another three nursing homes were reported. This was followed by a spate of articles describing failures in care.

The response: The government’s response to the scandals in 2006 was to police. New laws required police checks on employees. New regulations required sexual and other abuse to be reported to the police. At the time I considered this to be a band aid after the event measure that would only have a temporary impact. What had been revealed was the very disturbing cultures in these nursing homes. These were pointers to a wider problem and these laws would have little impact on that.

Writing about aged care: Starting in 2006 and during the next few years, I collected information and wrote roughly 100 web pages on my Corporate Medicine website. These described and analysed what was happening in aged care in Australia. On the web page linked to from the foot of this slider, I give more information about this period and provide links to some of the pages on my website. These contain quotes, references and links to original sources. Follow it as far as you need to, but don't get lost!

The 2010 scandals

I became more involved again when the next set of worrying exposures occurred in 2010 and when the Productivity Commission Inquiry 'Caring for Older Australians' was announced.  A young journalist won a prestigious Walkley award for her investigation of aged care. She worked undercover in two nursing homes owned by large corporate for-profit chains. They had both been accredited only a few months before. She exposed appalling conditions in both. These were then confirmed by the (then) Accreditation Agency. An examination of the two companies involved provides an opportunity to look at a number of issues in this marketplace.

The first company

The owner of one of the facilities claimed that this was isolated and not representative of the care provided by the company. This was debunked by a community group who collected recent accreditation data. This revealed that problems had been identified by the accreditation agency in 13 additional homes. Only a year later, a disaffected nurse deliberately set one of this companies nursing homes alight. Several elderly residents died in the fire that destroyed the home. In my view, the reports of what happened and the findings at the inquest pointed to disturbing management practices and a dysfunctional culture.

It seems that after the fire, this company did address the issues in its nursing homes. No further major issues have been reported in its facilities. My concern about the company’s response is that this was all done behind closed doors. We do not know what was done to stop the failures.

This might have been by tight management and intimidation to stop staff from speaking out and by focusing on passing the accreditation inspections. Whistleblowers claim that it is easy to game the accreditation process and that many do so. Alternatively, the company might actually have addressed the staffing and other cultural problems that had resulted in the lack of empathy and poor care exposed by the journalist.

In both the US hospital and aged care sector it was unusual for big chains to confront the profitable business practices responsible for failures and for the corporate culture. To do so would have impacted on their success in the marketplace.

What I am unhappy about with this Australian example is the lack of transparency and accountability about what was done. I am talking about full transparency and real accountability to the public, to the community, who are ultimately responsible and on whose behalf the care was being provided. This is something that should not be 'commercial in confidence'.

A change of name: This Australian company promptly changed its name. This is what big US companies have done to escape their tarnished pasts. The big US company I am going to use as a classic example of market failure on later pages changed its name and then made exaggerated claims to a new integrity and a commitment to ethical conduct. But it did not change its disturbing business practices. Some years later it was embroiled in another massive scandal. As part of the companies single minded focus on profitability, several hundred patients were harmed by performing unnecessary major operations. It had indulged in multiple other unacceptable and unethical practices.

Explaining this: The pressures in the marketplace drive companies to focus on their public image. They rarely change the profitable business practices that caused the problem but they do become more careful. They tighten their management of staff.

Interestingly, most of these US companies did not see themselves as being deliberately deceptive. They were simply unable to accept that their successful policies were flawed. The free market is built on illusions. The pressures it generates creates situations where people readily develop more illusions to make what they are required to do legitimate for them.

Empathy: There is another important issue here. The market is an impersonal mechanism focused on profitability. It has no values, no humanity and no empathy. Employees are expected to serve the interest of the company and its success in the marketplace. The stronger the competition the stronger the pressure on employees becomes to perform.

Displaying genuine humanity and empathy utilises resources including staff time. It is costly. Some nurses who speak out indicate that when they spend time talking to residents or complain about their inability to do so, they lose their jobs. Humanity and empathy are not encouraged by the market and are sometimes punished.

Dealing with relatives: If we look at the press reports about this Australian company we are struck by the angry allegations made by the relatives. It seems that the company did not engage empathically with them. No one from the company’s senior management bothered to come to the Coroner's Inquest to engage with the families, empathise and show what they were doing to address the problems. The families were angry and accusatory. If we look at this and then also look at what nurses across the industry are saying about their workplaces we get a good insight into how this market works and how our basic humanity is blunted.

Does the way this company treated these families throw any light on the changes that were made after the scandals in 2010 and a year later after the fire? Is their failure to attend the inquest the sort of conduct that senior management expect their junior managers and staff to follow in their nursing homes?

They seem to have been unaware of what these people were going through and incapable of showing empathy and relating to them. We need to ask whether they have any idea what the real problems in their nursing homes have been - the lack of empathy in their nursing home exposed by the journalist in 2010. Have they addressed this? Were the changes made only structural and not cultural. If their treatment of the victims families is a guide, then we have good reason to reserve our judgement about the changes they made in their facilities and distrust the glossy advertisements on their website.

The second company

The second nursing home exposed by the Walkley award winning journalist was owned by a multinational UK business. It had bought Australia’s largest nursing home chain in 2007. I looked at its record at the time and was sufficiently concerned about it to write to the government department responsible for approving providers.  I gave them information and asked them to consider whether the company was suitable for approval. But because the company it purchased already had a licence and because it was an owner - it did not have to apply for approval. This was the loophole that other multinationals had been using to escape assessment of their suitability.

Company wide problems: A re-examination of what was happening in the UK in 2011 and in the years after that revealed that allegations of failures in care in that country are as or more extensive than in Australia. This is one of the companies that have been strongly criticised. There have been allegations of problems in their aged care empire in England, in Scotland and in Ireland. In 2014, National Radio reported further problems in another Australian nursing home.

A third company

In 2012, reduced staffing was blamed for the death of a resident in a facility owned by another corporate chain. Three years later, another death in another of their facilities was alleged to be due to understaffing.

2013 to 2016: Recent developments

The Productivity Commission report was published in 2011. It claimed to be recommending major changes and much publicity was given to it.  It was simply more of the same with a greater focus on markets. The customers were going to have to pay more of the costs of aged care and there were going to be greater opportunities for companies to grow and expand. Everyone was going to be given 'choices'.  Consolidation of the sector into larger companies was encouraged and was seen as essential progress in an immature market by economists and politicians. These recommendations were adopted by government and the process was marketed to the public as the Living Longer Living Better reforms.

The Harper Competition Policy Review was released in March 2015. This advised greater competition in aged care - further ramping up the pressures in the sector.

Global commercial opportunities

The government increasingly sees the aged bulge in wealthy Asian countries including China as a commercial opportunity for Australia. It has been negotiating trade agreements to give our companies an advantage in this potentially lucrative market. They will be competing with large US and other multinationals. This may be why the pressure to consolidate and grow has been increased even though the evidence indicates that this resuts in poorer care.

The consequences

More active market activity and consolidation in the sector started in about 2012.  It accelerated in 2014 when additional money was made available by the Abbott government as part of the Living Longer Living Better reforms. Big companies bought up smaller competitors and several became profitable enough to list successfully on the share market.

These developments were accompanied by an increase in the number of press reports describing problems and more scandals. There were 6 ABC Lateline programs during 2013 describing problems in the sector. In 2014, the Woman’s Weekly magazine published a major article and there were publications from Canberra. During 2014 and 2015, many articles appeared in the The Age, the Sydney Morning Herald and The Australian. A Radio National program was damning about two nursing homes, one of which belonged to the international UK company.

There have been a series of articles complaining that relatives of residents were being barred from visiting their parents when they complained strongly about the care that was not being given. Other reports addressed the distressing experiences of younger people with major difficulties who have had to enter aged care facilities because there was nowhere else for them to go. In 2016, we have seen a number of excellent articles in The Age and in the Sydney Morning Herald describing what is happening.

A majority of the articles relate to for-profit owned facilities, many of them the larger chains. The volume and nature of all this material points to a recent more rapid deterioration in the sector. Far from being reform, the Living Longer Living Better program with its emphasis on markets and competition seems to be compounding the problems in aged care.

A new trend

There is another new trend. Not-for-profits owners find themselves having to compete with large and aggressive for-profits. We do not collect details about staffing in Australia, but international studies show that for-profits keep costs down by employing fewer staff. In both the USA and in Australia, for-profits on average have a greater number of failures in care.

Without an effective customer, this does not impact on their profitability and does not constrain them. The not-for-profits employ more staff and have fewer failures in care. They are unable to compete and are threatened. They have been forced to adopt for-profit thinking and practices.

We are now seeing occasional reports describing problems in not-for-profit facilities. Early warnings come from the nurses.  We are seeing letters to the press and comments below web press reports that describe problems in not-for-profit facilities and allege that it has become all about profit. This is what happened to not-for-profits in the USA in both health and aged care,

Gaming, rorting or maximising

Over the last few years, we have seen what has variously been described as 'gaming', 'rorting' or 'maximising' the funding system for profit. This has been recurrent and ongoing particularly since the increased marketisation and competitiveness of the reforms proposed by the 2010/11 Productivity Commission Inquiry. Every attempt that government has made to provide extra funds for special needs in the sector has been rorted, causing a blowout in costs. There is little if any evidence to show that the money all went to improve the care of the residents it was intended to help.

There is much to suggest that the additional funding promised for care in the 2014 Living Longer Living Better 'reforms' went to the business of the marketplace - profitability, growth, listing on the sharemarket and competitiveness.

2016 has seen an intense focus on the way that additional funding has been squeezed from both the funding system and from residents' pockets. Faced by a massive blowout due to gaming or maximising government has stopped the extra funding.  This has caused the shares of the market listed companies that had been particularly aggressive in the pursuit of these profits to tumble. They have complained bitterly calling this a cut to their funding.

At the same time there has been intense concern and a number of press reports indicating that funding for care and particularly for staffing has been diverted to profits. The many press reports on the linked page suggests that gaming and maximising profits at the expense of the residents is not a new problem, but has intensified as the market has consolidated, become more competitive and sought efficiencies.

An interesting article from the industry uses the concept of a 'game' between government and industry to downplay and sidestep the moral issues raised by finding ways of legally stealing more from the government's coffers. This it seems, is how the market works and they see this as legitimate. The authors suggest that the problem will disappear when the future policy of requiring residents to pay more out of their pockets and of handing any subsidies to them to use to buy the care they need.

• Why ACFI isn’t the only game in town Australian Ageing Agenda, 24 June 2016

An excellent article by Michael Pascoe in the Sydney Morning Herald reviews what has been happening. He rightly points out that the market is incentive driven and that the response to governments’ cuts will be to focus the game on residents and make savings there in order to maintain profitability.

He addresses the issue of incentivisation and points out that the incentives in the system are not to keep people well and active, but to have more sick people, and also to supply only minimum standards of care. The whole article is worth reading and the video on the web page summarises it.

My argument is that both the funding and oversight of care would be better placed in the hands of empowered local government and community controlled structures who would be in a position to see exactly what was happening and would not play games. The governments responsibility would be to support and train them, and ensure thay have the skills needed to monitor the system. That is what the proposed aged care hub is intended to do.

More detail and supporting material

The page linked to below expands on and adds to what is said here. It addresses some additional issues. The failures of the accreditation and complaints systems are exposed. It supplies links to or quotes from most of the material referred to showing what has been happening. It is not only the number of the reports, but the extent to which they reveal the culture of organisations that I find so worrying.

On the linked page I also comment on how the proposed Community Aged Care Hub would change the way this market operated and resolve the issues, particularly the problems of transparency, accountability, accurate data collection and the power imbalance.

Learn more: Scandal after Scandal

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Those who really know what is happening

The limits of the press

It is usual to decry the press as sensationalist and as more about getting a story than about the facts. There can be a lot of truth in this. The human costs tend to be emphasised, but the causes and complexities do not get reported. This does need to happen in order to engage people and get them to confront this issue. There are constraints because there does need to be a basis of truth. Aged care corporations are powerful and have good lawyers. Because the system is so opaque, it is difficult for them to get proof of the allegations that whistleblowers make. It can be quite difficult to get the press to publish your story.

The USA is far more open than in Australia. When I visited to study a company there in 1993, I met with the politician who chaired the first major inquiry. He gave me access to all the transcripts and documents of his inquiry as well as all the press cuttings. I met with fraud investigators who were very open and shared documents when they could. I spent time with lawyers who had collected large numbers of leaked internal documents. I met with or corresponded with the many whistleblowers.

Although this was a massive scandal and received widespread coverage, the reality was far more confronting and far deeper and pervasive than anything published in the press. It was not only about this company but about the way in which very confronting and harmful practices had been adopted by the entire industry and across the USA. I did not have to make FOI requests - everyone I met offered.

Real insights

But the most insightful information and depth of understanding in this company and in subsequent health and aged care companies that I investigated came from the people who had been there, the whistleblowers, administrators and the staff both doctors and nurses.  The stories of the patients who suffered gave more detail.  They were often quoted in press reports.

In aged care in Australia, the system itself is opaque but it is not difficult to find out what the staff and the families of residents, who have been unhappy about what they have seen, are saying and thinking.  Aged Care Crisis has been listening to them for many years.

What the people who know are saying

Many newspapers now invite comment on their articles. Many do comment. People write letters to the papers. Aged care specific digital news sites like the Australian Ageing Agenda do the same. Staff can speak out anonymously and many do.

In addition, we have recently had another series of inquiries to which submissions have been made. Staff are desperate for something to be done and many have made personal submissions describing what is happened in the nursing homes where they work.  Families have done the same.

What we are hearing is the cries of pain and the desperate pleas for something to be done. Strangely the cries are often more intense from staff than from families. They are responsible for providing this care and they are highly motivated to do so. There are simply not enough of them in many facilities and many do not have the training to provide what is needed. They see what is happening and are impotent to do anything about it.

On the linked web page I have assembled a large number of very short extracts from submissions made by people who understand what is happening at the bedside. What they are saying so clearly comes from the heart. They give a graphic picture of what too often happens to old people in our nursing homes.

The inquiries I have taken extracts from are:

• Future of Australia’s aged care sector workforce Inquiry by Senate Community Affairs References Committee 2016
• Registered nurses in New South Wales nursing homes General Purpose Standing Committee No. 3 Legislative Council NSW 2015
• Violence, abuse and neglect against people with disability in institutional and residential settings, including the gender and age related dimensions, and the particular situation of Aboriginal and Torres Strait Islander people with disability, and culturally and linguistically diverse people with disability. Community Affairs References Committee November 2015
• Elder abuse in New South Wales (Inquiry) 2015-16 General Purpose Standing Committee No. 2. Legislative Council inquiry.

I have also provided some links to several press reports which have generated a lot of comment, to a nurses letter, and to a web page containing emails received from staff prior to 2005. This has been a long and very painful ride for nursing staff.

Learn more: Those who know

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The Industry's response

In response to the flood of adverse criticism and the claims to excessive profits revealed in leaked private industry reports, Pxxx Jxxxx Kxxxxx, CEO of ACSA (the body representing not-for-profit providers) drew on the recent much larger publicly available December 2015 benchmarking financial report from the accounting firm Stewart Brown.

This described the financial performance as 'business as usual'. They found that it was a 'myth to suggest that the sector is reaping huge rewards' and that the additional income from higher subsidy rates was being spent on 'care costs - including on staff wages'.

While this is a much larger and supposedly more representative study, we are left wondering why there is such a startling difference between confidential and public reports, why the market analysts are so upbeat about the sector and why the market listed companies are reporting such large profits and rising share value to shareholders.  As a community, we don't have access to unlisted companies' financial data.

As I will show on later pages, widely differing but deeply held views are a characteristic feature of this industry.  The Canadian analyst of our western civilisation John Ralston Saul argues that our corporatist market focused society is driven by self-interest so that everything is seen from the point of view and the interests of individuals or corporations.  There is no concept of the "Common Good". 

In a civil society, one where society and not markets set the agenda the focus is on the Common Good - what is good for everyone. Civil society's involvement is without personal interest. There is a disinterested approach but the term disinterested does not indicate a lack of interest as such. I think Saul has hit the nail on the head. 

I will speculate on the why and how of this elsewhere.  Lets look at the proposal suggesting how the industry should address the criticisms of aged care.

Criticising the negative press reports and comments, Kxxx indicated:

We continue to see comments like the following in accreditation reports, but no effort is made to collect this sort of information, collate it and report it out, so we do not know its frequency and what is happening across the sector:

An anaesthetised industry: The leadership of the industry is deaf to the cries of pain and the pleas for help. The response to the staffing crisis in aged care is to ignore the cries of pain and the numbers who are despairing and leaving the sector. Instead, this is seen as an image problem to be solved by creating a positive image.

When you live in an illusionary world, you create the illusions you need about the real world when it challenges you.  The logical response is to address the problem by creating a counter illusion.

The history of responses to  criticisms of poor care

The early years:  The response to criticism is to minimise, deny and to claim that they are rare exceptions in an other wise excellent system. The criticisms and exposure of failures has been ongoing for many years. It comes in cycles. Look for example at the intense criticism that  was being made in 2000 and 2001 - then again in 2006.  Over the last few years it has got steadily worse.  It is time for real action, action that restores transparency and accountability.

It has never been resolved because neither the industry nor politicians have been prepared to confront the possibility that the experience of people is real and far too common.  Instead of acknowledging, collecting data and reconsidering policies, our blind leaders have refused to look at the issues seriously.  They have denied and then blundered on relentlessly.

• Bronwyn Bishop and the Riverside Scandal 1998 to 2001 Corporate Medicine website

Here are a few of the early responses:

2000:

2006:

Within days of this reassurance, women in several more nursing homes were found to have been sexually molested.

The latest responses:  Recent responses follow this pattern but politicians have learned to keep a low profile.  The industry and their supporters are attacking the messenger.

An industry website goes into it in some depth and makes their arguments to reassure their members.  This was a response to the press report that followed the leaking of the confidential Bentley's reports showing that profits had jumped but money spent on staffing had not.

The following two quotes are response to a recent articles critical of profits at the expense of care:

In response to the criticisms, ABC invited an industry supporter and gave him plenty of time. He brushed aside the many “horror stories” and claimed that we had a world class system recognised as such internationally.  There has been an angry reaction to this from those who listened and have made comments.

• Aged care ABC Saturday Extra (Radio), 11 Jun 2016

We are confused and don't know what to do so we disengage and don't try to sort it out.  It is civil society's role and the responsibility of citizens to do this but in a society driven by self-interest civil society has been emasculated.  In my experience pain and suffering are seldom illusionary and they are seldom things that ordinary people lie about.  They are very real experiences.

There are plenty of assertions and allegations from both sides, but none confront this divide in perceptions, explain it or try to resolve it. There is little publicly available data to inform the debate. Management don’t seem to hear or understand what people are saying. They simply deny and make no attempt to confront the allegations objectively. 

Instead there is a standoff and the two groups become more and more polarised. This is a feature of what I have called a culturopathy - where it is more important for participants to protect their beliefs than to collect information to resolve issues or address the criticisms. 

What is important is that when there are allegations that people are being harmed, then they be given the benefit of the doubt until that is disproven. While there is still doubt about this, reputation and financial considerations cannot ethically be given precedence over concerns about breeches of care and that is what this sort of response is doing.  With so much smoke we cannot ignore it.

What the system needs is knowledgeable genuinely independent members of the community working regularly in the facilities helping to collect data about nursing care, about standards of care and about quality of life. It needs the proposed Community Aged Care Hub.

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Implications

Over the last 19 years our aged care system has been characterised by periodic scandals and ongoing claims of failures in care as well as continuing unhappiness coming from those actually providing the care and those experiencing it. The accreditation process and the complaints system have been widely criticised and have done little if anything to reverse this trend. I do not believe that anyone can still dispute that the system has failed and has failed very badly.

Even if what the press reports and what participants at the coal face are saying is misconceived, they certainly are experiencing it this way.  In that case the relationship between industry and the community it serves has broken down and the industry has been unable to bridge the gap. That is no less of a failure.  Our aged care system is in crisis and so are similar systems in other countries.  It will be solved by communicating effectively and then sorting out what is happening and not by educating, which in this market is a synonym for marketing.

Crying poor: In response to failures aged care providers cry poor and claim to be underfunded.  At the same time some are making massive profits, buying up weaker competitors who often provide better care, and are performing well on the sharemarket. One leaked market report suggests that over the last year profits have risen 40% while money spent on staff has fallen 10%.  Publicly available reports paint a different picture.  Why?

A staff shortage: The number of trained nurses in nursing homes has fallen steadily since 1998. Providers regularly claim that there is a staff shortage and that they can’t fill posts. Over the years there have been complaints that graduates can’t find jobs.

2010:  In 2010, only 222 of 800 newly qualified nurses in Queensland could find jobs.

2012: The Examiner newspaper reported on 1 Nov 2012 that Tasmanian facilities were turning away graduates. There were 90 applications for 8 jobs advertised and only 111 government jobs available for 300 graduates. The private sector was not offering jobs.  ABC News even suggested that some would be on the dole and others would go to other states.  Problems were ongoing and in 2015 The Mercury revealed that even though the projections indicated that 5,000 new workers would be needed within 5 years, Level III graduate nurses still could not find jobs.

2013: In Victoria, healthcare cuts in 2013 saw hospital nurses fired because of cuts and 43% of nursing graduates could not find jobs.

2014: Half way through the year in 2014, ABC Lateline interviewed nurses and obtained figures showing that “About 8,000 nurses graduate from Australian universities each year. But this year up to 3,000 cannot find work”. They indicate that “nurses haven't managed to get jobs in hospitals” and that it "has become a nationwide problem, made worse by the 3,000 foreign nurses arriving in Australia each year on the 457 visa program". Aged care is not mentioned in the article. Was it so unappealing that these nurses did not apply, or did the industry not welcome the opportunity because it would impact the bottom line?

• Nurses can't find jobs ABC Lateline, 23 May 2014

2015: ACSA published a position paper on the workforce.  On page 9 it addresses the issue of shortages.  It pointed out that the 3,000 shortfall in places for newly trained registered nurses was an opportunity for aged care.  But we need accurate data about where new nurses go.  Do the providers pursuing profits actually want them?  If they were still unemployed 6 months after graduation, then they were not being snatched up by the industry or being given aged care support and mentoring.

• The Aged Care Workforce in Australia – Position Paper – ACSA, February 2015

2016: This is still happening. Information about the employment of lower paid staff over skilled staff was given in evidence to the Senate Workforce inquiry on 28 April 2016 by the Health Workers union. They indicated that over the last 5 years registered nurses have fallen from 20% to 13% of staff. Providers were employing Certificate Level III ########## staff in preference to better trained but more expensive level IV staff so there was no incentive for staff to improve their training and skills.

The union also indicated that “There seem to be some employers more than others that are attracting 457 visa holders. For example, FPCompany Newname C made a lot of positions redundant, especially throughout the Gippsland region, only to then advertise those positions and advertise that people with 457 visas may apply. There are other organisations which, because of the very poor treatment of the staff, cannot attract local employees any more because they have such a bad reputation. They are also advertising for 457 visa people to work for them”.

From the reports and the accounts of nurses, it sounds as if the aged care industry expects government to employ new graduates and give them practical experience. It is not prepared or interested in taking on the role of giving these nurses the supervision and practical experience they need and so recruiting them to aged care. Many claim that the industry will only employ them in junior assistant nursing roles. 

At the same time, the industry is embarking on a "national positive image campaign" to bring more young people into the industry.  But will they take any responsibility for mentoring and training them?

The industry offer a number of explanations for not employing new graduates but once again, we are faced by contradictory information and we have no way of finding out what is actually happening.

Throwing more money at it: One thing is clear from the Living Longer Living Better reforms and that is that any additional funding is unlikely to go to care and would be wasted. The system may need more funding, but that should only happen when there is a process in place to ensure that it goes to improving care and the quality of lives - not to the business of being successful in the marketplace, not to offering multiple unrealistic money making choices and not to funding corporate global expansion.

The impact of globalisation:  Government has been actively supporting the consolidation of the aged care marketplace.  Bigger companies are rapidly buying up competitors and we are ending up with fewer and fewer but bigger and bigger for-profit companies many of which are listing successfully on the share market. This does not come cheaply. It seems likely that much of the extra money which individuals are paying under the Living Longer Living Better reforms is fuelling this process rather than going to care.  There is much to suggest that this is where government wanted the money to go but they did not want to tell us that.  There is now incontestable evidence from the USA and from Australia that these larger for-profit chains provide inferior care when compared with the not-for-profit owned facilities.

At the same time, our government has negotiated international trade deals in the provision of services including health and aged care - the most notable and widely promoted is our trade deal with China. That aged care is a major and badly needed service in these countries, one which we aim to capitalise on has not been strongly promoted to the public.  But Malcolm Turnbull took a large delegation of businessmen to China in April 2016 and this would have included some of our aged care barons.  By the end of the month the first deal to supply China with aged care services had been signed.  We do not know how many are in the pipeline.

To provide competitive international aged care services, Australia needs large powerful corporations that can compete in this market with the US and European giants.  These are known to provide inferior care and politicians must know this.  It is difficult for a sensible person not to conclude that they are deliberately pursuing a policy which reduces the quality of care for Australians in order to sell the Chinese something that actually provides inferior care.  But we must remember that policy is driven by belief and not by common sense.  When you truly believe you either don't see or don't acknowledge what you see even to yourself.  I cannot bring myself to accept that a democratic government would sell out its citizens in this way - not unless they were deluded which in this case seems more probable!

Worse still, this policy has painted government policy into a tighter and tighter corner - an ever greater "paradigm paralysis".  To make changes now they will have to acknowledge that aged care is a failed market and they will have to admit this to their trade partners and lose face.  This is why it is the community that will have to take up this issue and force the changes we need to protect ourselves from the consequences of the policies of the limited number of political parties we have to choose from when we vote.

Looking more closely: In the following pages I am going to look at our aged care system in several different ways. I am going to argue that aged care is becoming or has already become a culturopathy - a diseased cultural system. This is a system where the main cultural participants believe implicitly that what they are doing is the correct way. Its not that they are intentionally malign or wicked.  They are simply deluded and live in a world of their own. Their lives are so heavily invested in this and the belief becomes so important to them, that they don’t see and if they do they simply dare not acknowledge. Their psychological behaviour and the social dynamics follow an easily recognised pattern.  It has happened before and we still have not found a way to ensure it does not happen again.

It is not unique to aged care as there are multiple other examples although they may present differently. It is not unique to Australia as the same things are occurring in other countries. It is not unique to our free market system as there are examples where true believers have wreaked havoc and caused extensive harm in the recent and distant past. It includes some ideologies but it also occurs in cults and other small group situations.

Finding another way: Along the way I will be looking at how a community based solution like the one I have suggested would work to address the issues when seen from each different point of view, whether these be market theory, political process, social process or some other paradigm.

Once well established, culturopathies respond to criticism with aggression. Too often this ends with violent conflict of one sort or another. Many can be harmed. There are a few exceptions to this to guide us.  I am suggesting a way out that I think will not end in too many tears, but change does not come without some losers.

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Changing the way we provide aged care

In aged care there is a growing dissident movement - those who see what is happening and want to do something about it. They still have differing ideas and many are responding instinctively rather than looking at what has been happening here and elsewhere, reflecting on it and then planning constructively. The big problem for this group is that like all dissenting groups, they lack power and credibility and have not yet started talking constructively to each other and coordinating their activities. 

We have recently become aware of resident and family groups that seem to be very organised and strategic in their efforts.   They are using the power of numbers and their ability to accurately document what is happening in the facilities to confront management and when that fails to access the regulatory system.

The linked web page looks at the struggles that some have had in the past - the sacrifices and efforts they have to make to win small battles.  It then looks at what has happened recently.  Groups of residents and families are being more successful and achieving outcomes.  But these remain small battles. To make changes to the system itself in this way is going to take many years and many will suffer. The heritage of distrust and anger will last for years.

What these residents are doing is exactly what the aged care hub is intended to do on a permanent basis.  On the linked page I look at how the proposed community aged care hub would institutionalise what the residents are doing and create a situation where residents and families with the community standing behind them would be working together with the providers in managing the complexities of aged care. Situations like those these residents were forced to tolerate would be prevented because management would have to discuss matters with residents and community (their customers) before making any changes.  Any problems would be detected early and acted on immediately.

The proposed Community Aged Care Hub is an attempt to short-circuit the years of conflict and the heritage of alienation and distrust that so often accompanies resistance and action by vulnerable groups in society as they fight to confront the consequences of the self-interested but more powerful  and make changes for the better. 

There are good arguments within market theory and plenty of historical and current practical experience to support the community aged care hub model. It is a model for creating a customer and a community of citizens with the power to control this market and to force the provider to engage with their issues.  Until the 1980s this model of society was unchallenged. It formed the basis of our capitalist democracies and was why they were so successful.

There are no credible arguments that can be used to dispute the efficacy of our proposal in creating a more humane context for aged care. It would build on the efforts of groups of residents and families who are already organising and working together.  It would support them in what they are doing and join with them when they need help.

We need to mobilise a sufficient number of people to force these arguments into the public arena and make what these groups are doing part of the way that community and providers work together to provide better care and a better quality of life. We can help them to work together and support one another.

The linked page explores these issues.

Learn more: Steps to the hub

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