Policy in the dark

1. Policy made in the dark and without considering evidence

Data

No local data collected: Data about failures in care, levels of staffing and the skill profile of staff, have not been collected and reported in Australia for at least 20 years if not longer. Policies introduced into Australia were done in the dark.  They were based on a misunderstanding of the benefits of markets that had developed during the 1970s and 1980s. 

The ideas were so appealing and so widely accepted that the Howard government restructured health and aged care in 1997 along the lines of these economic theories even though they were aware that failures were already widespread in the USA. 

While there have been multiple inquiries, none of these have had reliable data to use.  None considered the data that was being collected internationally.  The policies and the belief system on which they were based have never been challenged or reconsidered.  Most of the problems that we have in our aged care system can now be seen as a consequence of these failures.  This section of the web site examines the failure of these policies and the theories that underpin them.  It explores the reasons for this failure with a view to addressing them.

International data: International data showing the disparities in staffing and standards of care between different types of provider has recently been reviewed and reported on by academics at The University of Technology Sydney (UTS). I am aware that since 1994, international studies have shown that large corporate for profit providers, and particularly private equity groups, have on average many less staff and more failures in care than not-for-profit providers. These researchers have reviewed the international literature and confirmed this.  I quote some of this material later.

Looking at what is available: As these researchers found there is insufficient data collected in Australia to do similar analyses but the UTS group have been able to show that for-profit providers in Australia are sanctioned for poor care more than twice as often as not-for-profit providers. More information is here. The crude accreditation figures reported by the Quality Agency also suggests that if properly analysed not-for-profits would be shown to be performing much better. This is what a limited study by Aged Care Crisis in 2008 also suggested.   There is also the impression from disclosures in the media that for-profits have been involved in the reported failures in care more often.  Solid confirmatory data is lacking.

The impact of location: The UTS group argue that there is little money in rural areas to attract providers who need to compete and that this policy will consequently lead to a two tiered system.

It is interesting that the minister has accepted this as correct.  Her explanation, which avoids addressing the rest of Baldwin's evidence  showing that the market is bad for care, simply reveals how paralysed policy is.  It is not clear how she will finance the rural sector.

Was aged care originally intended to be a two tiered system?: We need to remember that a two tiered system is exactly what the aged care industry wanted for all of Australia in 1996, not only between city and rural areas. This is the way they thought. It is probably what government thought at the time as well but they bowed to the pressure of a massive backlash and accepted some changes to their policy.

The aged care policy was largely written by the industry which bankrolled the governments election in 1996. Their most influential member was quite open about this on television. In giving evidence to a senate inquiry in 1997 the Chairperson of Uniting Church’s Community Services Australia stated

When the government bowed to pressure and watered down some of his policies Mr Moran was furious and resigned from the party. We can only surmise that the party he had supported so strongly and helped into power was reneging on undertakings given to him.

Not for profits: I agree with analyst and strong critic, Robert Kuttner’s, 1996 assessment in the USA that market pressures cause not-for-profit providers to behave more like for profits and employ similar practices so that their care also deteriorates. I look at Kuttner' articles on the not-for-profit web page in this section at these issues in Australia in the Cultuural Perspectives section.

Strongly disputed allegations of poor care in a local church based not-for-profit discussed elsewhere on this site raised questions about this - but because we don't have solid data and because we have grave doubts about the utility of the quality agency which does not collect and report on actual failures in care, we do not know what really happened there. The company certainly won its battle with the quality agency whose assessments were not upheld in court. The court made the agency pay $25,000 for the company's legal costs. 

We have argued that the quality system is flawed and not reliable. Because it does not collect and record the frequency of actual failures it lacks precision and is not equipped to sustain its decisions when they are challenged.  Its lack of precision leads to errors in both directions.

Following the money: For-profit providers are following the money and focusing on the wealthy. They are building luxury facilities where they can charge large bonds, sometimes up to $1 million so enabling them to grow even more rapidly.

Not-for-profits with less access to market capital are trying to compete by targeting the rich as well and are also building aged care palaces in order to get larger bonds.

With the competition focussing on the wealthy, the average middle class and poorer Australian battlers are going to be left with the leftovers. Because they are less profitable, resources will be directed away from them towards the more profitable. There will be less funds to care for them and they may have difficulty in finding services as well as paying for what is becoming an increasingly costly service.

The public policy website, The Pulse, has recently published an article that looked at what is happening and addressed this issue. They point out that, for the average Australian, home ownership is decreasing and superannuation is limited.

The response: form a guild

The pressure of the evidence on politicians is growing as is community distrust and unhappiness. The industry has responded by forming an Aged Care Guild comprising nine of the largest market focussed groups in Australia to lobby the government.  This gravy train for the big companies depends on government support ald continued funding for tyhe Living Longer Living Better "reforms".  We can expect a marketing campaign and renewed publicity from NACA and COTA.  If the USA is an illustration of what happens, then expensive lobbying and political donations might increase.

The importance of political decisions for their future is clear and we can understand why they use everything in their power to keep politicians controlled and thinking their way.

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The response of industry to publicity about problems is not to engage or to address the problems, but to see the publicity as the problem and counter that with positive marketing.  Faced by less funding and mounting criticism in 2016 ACSA is mounting a National Aged Care Open Day.  The industry is lobbying strongly for more money and needs a positive image. It is time to stop dealing in images and start looking at facts instead.

2. Turning everything in aged care upside down

In 1997 long established principles and knowledge about the threat which selfinterest posed to the vulnerable in our society were abandoned.  A sector in which marketplace transactions were restricted to those with a sense of social responsibility, where the interests of the vulnerable were prioritised, and where transactions were controlled by community and ethical expectations was abandoned. 

It was replaced by one introduced from outside where all restrictions on participants were abandoned and where interest other than those of the vulnerable became the driving force in the system.  These two patterns of thinking can be considered as the not-for-profit replaced by the for profit approach.

Not-for-profit thinking

When care is provided for the benefit of the community then the first step is to see what the community need is, then design a facility that will meet that need, and finally find the money and a way to build it.

You tell those in the community what you are doing and those in need come to you for help. The next step is to see what the recipients of care need and will benefit from. The same process of finding the resources needed to meet that are followed. What can be achieved is restrained only by what is possible and the commitment to attaining it. That is what a not-for-profit system focussed on the community once did and much less often still does. It may have struggled to get the funding but this was the thinking and the mode of operation.

For profit thinking

In the market you look for opportunities to make money. First you look for a community that has the wealthy elderly you want to come to your nursing home. Then you design the sort of facility that will attract both the wealthy eldely and investors. Then you ask investors to put up the money by promising them large profits.

When the building is up you proceed to advertise what you have to offer and entice as many as possible to come to your nursing home. Once there, your interest is in making as much money from them by offering them as many profitable services as they can be persuaded to pay for.

The final thing is to ask if that can legitimately be done. It is very easy to confuse what the recipient actually wants or needs with what the business wants and needs. A little rationalisation helps to ease your conscience and increasingly we persuade ourselves that what we want to do is legitimate. When others are already doing it then it is easier to persuade ourselves.

When people lack knowledge or power they readily accept what they are told they need or would benefit them. The entire health or aged care system can be distorted and become dysfunctional.

This is not exceptional behaviour and it readily becomes the norm. Someone in the system will detect any vulnerabilities in the system, find a way of justifying exploiting it and others then follow. We humans are incredibly malleable. Our ability to adapt to any situation we find ourselves in is why we are such a successful species. This is the way individuals behave and in doing so they reinforce each others beliefs. This is Social Darwinism.  Evolution does not have a conscience only an outcome.

There are many examples to illustrate what happens.

The first problem

The problem now is how to make the market do what the citizens in those early communities wanted when they first formed those local not-for-profit organisations to care for those who could no longer care for themselves.  The market is not doing that. Most of us probably still want that at a minimum even when we want more. In a balanced well structured market it is powerful customers who insist on getting what they want.  Our first problem then is that we don't have that sort of customer in this market and without it people will be exploited.

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3. The Process: Reform gone wrong

It might be a good idea to look at where we have gone wrong during the most recent attempt to "reform" what was already a failed system.  Did anyone look at why the system we had was failing?  That would have meant confronting belief and accepting that their belief in free markets was not a universal truth and it did not always work. 

Finding out why something is not working is the first step in gaining insight into system failure.  Without it we were doomed to making the same mistakes.  The Productivity Commission was told why the system was failing in submissions but it elected not to confront that information and simply ignored it in its report.

A. The Productivity Commission

Ostensively set up to review a failing aged care system the Productivity Commission was constrained by government, by the background of the commissioners and by the power of the marketplace. It could not examine and confront the reason why the system had failed. A solution where the free market corporate marketplace was not central to their recommendations was not possible or tenable for any of them. The Commission's 2011 report reflected this.

B. Community consultation

Two bodies, Alzheimers Australia and COTA were commissioned to consult the community and they did so in the second half of 2011. The community were asked what they wanted, but they were not consulted about how this should be provided.

Alzheimers reported that:

COTA was awarded a $410,000 non-contested contract by the federal government to conduct conversations.  COTA reported on what the seniors they interviewed wanted.

COTA were criticised for interviewing only their limited constituency and not the wider community and not critics of the system. The consultations were not widely advertised and the question of what sort of system we should be developing was never canvassed or debated. It had been decided by the Productivity Commission.

• Ageing conversations: as slow as a messenger pigeon? Aged Care Crisis 23 Feb 2012

National Seniors, Australia’s largest seniors group warned the government not to blindly follow the Productivity Commissions market focused recommendations. National Seniors found that its members were deeply ignorant of the entire process. There had been no broad discussion in the community.

C. Redesigning the aged care system

During 2012 the industry, The National Aged Care Alliance and other stakeholders were extensively involved with the Department of Health and Ageing (DOHA) in discussions as the system was redesigned. The bill for the new reforms was introduced in May 2013.

The Senate Community Affairs Legislation Committee Aged Care (Living Longer Living Better) Bill 2013 [Provisions] and related bills May 2013 report describes the extensive consultation process with stakeholders that was undertaken in the development of the LLLB reforms. It seems that the wider community were not considered to be stakeholders.   Seniors organisations did participate but the opportunity to get people involved and talking about this was lost..

On page 211 it states that “Stakeholders and the general community were able to provide written comments on the proposed changes during a four week period (21 November 2012 – 21 December 2012)”.  The only community consultation it seems was a 4 week window of opportunity to make written submissions while most of us were on holiday or preparing for Christmas. Did they want to hear from critics or avoid them.

D. The outcome

1. What eventuated was a complex system created in a way that could not possibly work. Twentieth century free market and managerial thinking could not be and was not challenged. It was not possible to obtain the objectives (what citizens wanted) with the system they designed.
2. The new system was not based on data and no one had asked why the system introduced in 1997 had not worked. Many still believed that it was working. As a consequence, the same problems were transported into the new system. A vast amount of effort was expended making the same mistakes all over again.
3. The errors were compounded by Tony Abbott who in 2014 had the task of finally implementing this system. He needed big corporations to meet his plan to make more money for Australia by providing health and aged care to China and other Asian countries. His policies of corporate consolidation, increased competition and efficiency destroyed any chance of all this goodwill and effort working. All three are harmful when applied in excess to a vulnerable sector like aged care -and without any effective restraint on marketplace excesses.  He made it clear that market processes had to be at the heart of any changes.
4. What we have ended up with is a complex, inflexible, centrally organised and managed and top/down process driven system that is confusing and cumbersome. Far from producing the empathic and caring service needed, the centralised bureaucratic structure restricts and inhibits our ability to enter the lives of others and to empathise with them. Inhumanity is institutionalised and so integral to the system.
5. The market system with its focus on competition to increase profits and growth, and its drive for efficient processes creates a context where resources are moved away from care. Those working in the system are unable to give expression to their humanity. Being humane and empathising cannot be done efficiently and any attempt to do so limits profitability.
6. The need for an effective customer and an effective community to restrain markets if they are to work was ignored. No attempt was made to confront the extreme vulnerability of elderly people and their families in the face of a complex system and a ruthless market. Only lip service was paid to empowerment. In capitalist democracies it is the community that has the power to decide what is acceptable conduct in the provision of services. Local communities have been excluded from the entire process.
7. It is now well established that success in the provision of community services is largely dependent on involvement and a measure of control by the communities served. Instead communities have been excluded. The belated and woefully inadequate attempts to educate the community fell on deaf ears as no seious attempts had been made to engage or involve them during the entire process.
8. In this system large sums of money are absorbed in the bureaucratic process, even more is devoted to the processes of managing the market and competing, and then there is the imperative to generate profits for shareholders, consolidation and growth - leaving care itself severely under-resourced. If costs and outcomes are considered, then it is the most expensive and most inefficient system that could have been designed.

E. What we needed

1. What was required was a simple and flexible system that could rapidly and easily respond to the needs of individuals.  To do this it needed to be based in each local community. The community, the repository of our human values, should have been intimately involved in this and been given a measure of control.
2. By bringing the control and funding of the system and the community to the bedside we make it personal, empathic and responsive. Providers would then have no choice but to give the community what they require. The money that is available would not be squandered.  It would go to care. This is what the proposed community aged care hub is intended to create.
3. The reform process could have started in the community among those who had experienced the aged care system and it could have been built working with them.  That would have been a sensible way to start addressing the problems that had arisen. It may still be possible to rescue the good ideas that are behind all this and release them from the chains that now bind and restrain them.

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4. The government knew what it was doing. Was it deliberate?

An advocate for participatory democracy was there

The manner in which this was done is out of step with trends in the provision of the public service. One of the most senior of public bureaucrats over two decades, Prof Pxxxx Sxxxxx, was a strong advocate for Open Government and Participatory Democracy. He has been chancellor of the University of Western Sydney among other jobs, is a former secretary of the Department of the Prime Minister and Cabinet and a former head of the Public Service Commission.

He is a member of the New Democracy movement and his biography there states “Pxxx supports the Foundation as a result of his belief that the revitalisation of participatory democracy in Australia depends on empowering citizens. New forms of engagement process are vital to this end”. He has given presentations promoting Democratic Dialogue. Citizen’s assemblies, people’s forums, citizen’s services.  In his 2010 presentation Empowering communities to transform democracy, on vimeo, he enthusiastically promotes community participation  and expresses his belief in outsourcing.  He focuses on not-for-profit activity and innovation and hardly mentions the market. He ignores its focus on self-interest and lack of social responsibility for the public good.  Yet it is the market that has seized the opportunities he gave them while in government and not the community which he is seeking to involve and harness. It is the dominance of the market and the failure of community to take control that has destroyed his projects as much as the politicians whom he blames. 

He has actively promoted online community participation. He has pressed for “New models of local area governance” that “that better meet the needs of individuals, families and communities at the local and regional levels”. He advocated program flexibility “responsive to the distinctive needs of a neighbourhood, region or area”.

He considered “Australia’s progress on open data policy implementation has been fragmented and lacks sustained conviction.”

He has espoused “new forms of citizen engagement both through increased sharing of government data and information and by providing more online opportunities to participate. Technology solutions, including digital democracy, can empower citizens to exercise the greater discretion they are being given”, “finding ways to devolve power and influence to citizens, communities and service-users” and “Implemented well, citizen engagement can improve the design and responsiveness of services, build social capital, encourage civic participation, and build greater trust in democratic institutions”. He complains that “citizen-centred approaches - - - have so rarely been built into major programs”. He urges “new policy proposals should include a trial or demonstration stage, allowing new approaches to be developed fast and evaluated early”.  This is what we would all want.  It is why I have suggested a community based solution.  But why didn't we get anything remotely like this?  Why did he later become chairman of FPComppany NewnameC, a for-profit that had a poor background rather than a not-for-profit?  Did he think he could change the way they thought and operated?

Being selective: Sxxxx does not confront or comment on the fundamental difference in perspective between for-profit and not-for-profit. He is selective in his advocacy insisting strongly that public service briefs to politicians should be confidential and not be subject to FOI. How can you have participatory democracy when important documents are not available to participants?  Perhaps the clue is the fear of "political mischief" because that would have challenged cherished beliefs.

Publications:  Material he has written including several government reviews reflects these perspectives

• Service Sector Reform: A roadmap for community and human services reform Final report (Victoria) July 2013
• Learning from Failure: why large government policy initiatives have gone so badly wrong in the past and how the chances of success in the future can be improved August 2015
• Sxxxxx Urges Community and Public Service Collaboration Probono 11 Feb 2016
• The Sxxxxxx report: freedom from political mischief can trump freedom of information The Canberra Times 1 Mar 2016

Sxxxxx is not alone in these views as his reports are based on discussions with colleagues. A government research paper addressed similar issues in 2011.

Why was the public excluded and public debate avoided?

How do you embrace participation and open democracy when you see criticism in the press as "political mischief"?  Is the flexibility to adapt your beliefs to what suits you a requirement for success in the public service?  What was needed to have the elephants in the room addressed during this discussion process was plenty of political mischief.

Sxxxxxxx was there but did not hang around. In March 2014 he was appointed by the Abbott government as Chair of the Aged Care Sector Committee to Lead Federal Aged-Care Reform. In November 2014 only 8 months later he resigned to become chairman of FPCompany Newname C.  There is not much to suggest that the company has adopted a community consultative approach under his care.  But he has continued to publish articles in the same vein.

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