The Nature of Care

Fine 1992 to 1999

1992

The Mixed Economy of Support for the Aged in Australia: Lessons for Privatisation Peter Saunders and Michael Fine SPRC 1992

In 1992 the SPRC participated in the growing debate about the benefits of privatisation by analysing past performance. They concluded that

• simplified approaches to privatisation provide an inadequate framework for analysing the complex mix of finance and provision involved in support policies for the aged in Australia.
• analysis - - provides little comfort for those who see privatisation as sure-fire means of cutting costs, increasing efficiency and expanding choice.
• past experience in the field of aged support policies provides evidence that privatisation offers no universal cure to the problems with which the Australian welfare state has been grappling for some considerable time.

1995

Three Years At Home Final report of the study of Community Support Services and their Users (250 pages) Fine M and Thomson C, SPRC May 1995

SPRC reported on a detailed three year study of 60 elderly people needing support in a large suburban area comprising 200,000 people. They found that the bulk of the carers were family members, usually women, and that formal support services were supplementary. These were crucial at certain times in helping and supporting the family and so making it possible for them to continue caring. They were often not used and were also refused as recipients were “frequently proudly independent”. They found that the care was based around “cultural or moral values shared to an extent by participants, caregivers and services alike”.

 1999

THE RESPONSIBILITY FOR CHILD AND AGED CARE SHAPING POLICIES FOR THE FUTURE by Michael Fine SPRC Discussion Paper No. 105 August 1999

SPRC revisited the policy issues for both child care and aged care. The government were now focusing on the market because of “unprecedented demographic, economic and political pressure”. The paper examined the history of aged care tracing it through labor’s reforms in the 1980 and 90s which were intended to “to harness the runaway market for care and to introduce an equitable, balanced, planned national program of services, redistributing existing government finance to expand community care”. Then in 1997 the Howard coalition government placed “increasing reliance on user pays principles and the market, bringing in additional entry payments and income-related fees to nursing homes and community services, fostering competition - - -“. Through most of this history there had been a “pattern of increasing formalisation and public support of care provisions”.

The paper published 2 years after the changes in 1997 asks whether the invisible hand of the market can become the helping hand of the future? It finds that the evidence suggested that “that the combination of public funding and private enterprise care provisions is a rather potent mix, and not one which can easily be advocated by those interested in containing the cost of future public responsibilities for care”. They referred to “the potential value of an ageing population in the formation of social capital - - - but this would not be realised in a system in which profit and individual gain is the main motive”.

The paper points out that retirees can be active for 15 to 25 years. It suggests that they could be given training in care and be paid to provide services as part of a “partnership in care” but then concludes that this was “unlikely to satisfy fundamentalists of either the right or left of the political spectrum”.

 Coordinating Health, Extended Care, and Community Support Services Michael D. Fine PhD Journal of Aging & Social Policy (1999), 11:1, 67-90, DOI: 10.1300/J031v11n01_05 

This 1999 paper looks at the issues of fragmentation and coordinating in the sector. The article examines policy makers attempts to address them in Australia with a view to improving cost effectiveness through microeconomic reform. The concerns are not new but the solutions are “fundamentally different from those more individually oriented and intermediary models identified earlier”. The paper argues that “coordination at the street level is very much constrained if government policies that direct the services lack coordination themselves”. It refers to “new models of organization and administration that seem to fly in the face of what has been orthodox wisdom regarding organizational structures”. The paper looks at developments contrasting the two periods.

A ‘‘small is beautiful’’ approach to community-based organization had changed with “the radical sundering of the public sector heralded by the New Public Management (NPM) of the 1990s”. These policies coupled with professional divisions have contributed to fragmentation. Perverse financial or organizational incentives can result in duplication as well as a system that is “skewed towards more intensive and expensive interventions than are required”.

General Practitioners, the traditional entry points for all forms of care have become increasingly isolated from those they refer to the system, as well as from other community services. They often have limited knowledge of services. Services are often “more competitive than collaborative”.

Information services in the past were provided by local, nonprofit community groups. These encouraged informal networking across organisations and more formal meetings which suited “volunteers or wage and salary earning staff, whose working conditions do not penalize their attendance”.

Case management has more recently become a popular and sometimes effective solution but it is a high costs piecemeal response to the problems created by the marketplace and it has been oversold. Capped, pooled funding in the marketplace was trialed in the 1990s hoping to get ”redistributing across cases to maximize the return on spending”. There were industry concerns about this. Others in contrast saw increased competition for limited funding as distorting the service.

(Note that until recently cross subsidisation by nonprofit community providers has been common. Many depended on it and its abolition under Consumer Directed Care has created problems)

The paper concludes that if local coordination is to succeed then relations with government bodies should facilitate, rather than impede, their development as was happening. Funding must be supportive of local coordination. The balance of care framework in place before 1996 provided this but the changes introduced since then “could prove to be a very serious threat”. It was critical that the “contribution of nonprofit voluntary agencies as the major providers of community care” not be displaced.

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Fine 2000 to 2007

2000

‘User pays’ and other approaches to the funding of long-term care for older people in Australia MICHAEL FINE* and JENNY CHALMERS Ageing and Society 20, 2000, 5–32

The welfare state grew and took responsibility for care at the same time as the traditional carers, women, moved into the workforce and were no longer at home to care for the aged. Increasingly care was provided in institutions.  The rapid growth of the aged population is occurring at the same time as the number of working taxpayers is decreasing. The state is financially threatened and is looking for a way out – both by shifting care back onto families that are less able to cope and by making users pay much more by using a market mechanism.

In a 2000 paper Fine and Chalmers examine this issue indicating that “support for older people can no longer be taken for granted” and that “like health care, care of older people is shown to lack key characteristics of commodities that can be suitably traded on the market”. They consider this inequitable and argue that some sort of cross subsidisation and risk sharing is desirable. The market was simply a way of “shifting responsibility for funding away from government”. They review the requirements (perfect information, freedom to choose, freedom of entry and exit, perfect competition, and the absence of market failures) and conclude that “these conditions do not apply to the field of aged care”.

They also argue that the market would distort services by favouring profitable services. It explores the various types of insurance and international experience with them. It finds that “market models of finance have not worked well in the field of aged care”. They quote sources for objectives for funding systems that include

1. Covering catastrophic costs or stressful burdens on families
2. Care not dominated by a set of perverse institutional and financial incentives
3. Claims should be sustainable
4. Individual savings should be encouraged, not deterred

This source considers that aged care is no different to health care so should be funded with or as part of a Medicare type of system. The authors of the paper support this.

2005

Dependence, independence or inter-dependence? Revisiting the concepts of ‘care’ and ‘dependency’ MICHAEL FINE and CAROLINE GLENDINNING Ageing & Society 25, 2005, 601–621.

Fine and Glendinning challenged the way in which “care giving” and “dependency” are seen as separate entities and are analysed separately. Care giving is pictured as an unequal relationship where there is a wide disparity in power. One provides and the other passively receives. Feminism has characterised this as a burden for the carer. Too often ‘care’ is seen as a “heart-warming concept with a positive valance, dependency is cold and its connotations are almost entirely negative”.

The authors analysed the literature and suggest that both care and dependency should be looked at together as part of the same process and this should involve a “rebalancing of power through the recognition of interdependencies”. Dependency in fact draws people together and is “a social relationship in which the behaviour and perceptions of all the actors contribute to the construction of the situation’”. Care can involve “positive interweaving of a ‘complex, life-sustaining web’ of connectedness between people”. Two older people can “negotiate care-giving and receiving” and this can maintain “a sense of self and personhood intact”.

More broadly in society there could be “‘nested-dependencies’ that characterise ‘exchange-based reciprocity’ so that within societies we see a “chain of obligations linking members of a community”. The argument is that “qualities of reciprocal dependence underlie much of what is termed ‘ care ’” and this is “the product or outcome of the relationship between two or more people”. Both define their autonomy and identity through the relationship.

Why caregivers of people with dementia and memory loss don’t use services Henry Brodaty, Cathy Thomson, Claire Thompson and Michael Fine Int J Geriatr Psychiatry 2005; 20: 1–10.

In their 1995 study Fine and Thomson found that carers often did not use available services. In 2005 the group explored this among the carers of those with dementia. They found that carers “have substantial need for a variety of services” but many were not using them “because of perceived lack of need or lack of awareness”.

2007

Uncertain prospects: Aged care policy for a long-lived society by Fine, M. .In A. Borowski, S. Encel & E. Ozanne (Eds.), Longevity and social change in Australia (pp. 265-295). Sydney: UNSW Press. (2007)

A chapter in a book reviews the development of aged care and considers it as a work in progress. It emphasises that it is erroneous to claim that the demography of ageing makes it inevitable that public responsibility cease and that the future of aged care be left to the market. It finds that the tensions besetting the existing system will have “a profound effect on the way services develop over the coming decades”

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Fine 2012

2012

Care: A Critical Review of Theory, Policy and Practice by Kirstein Rummery and Michael Fine in SOCIAL POLICY & ADMINISTRATION ISSN 0144–5596 DOI: 10.1111/j.1467-9515.2012.00845.x VOL. 46, NO. 3, JUNE 2012, PP. 321–343

A review of theory, policy and practice suggests that care “is a source of critical tension in current social theory”. The review “explores a critical synthesis of conflicting normative and theoretical positions regarding the giving and receiving of care, and of the ethics and justice of care”. The authors argue for the development of a ”citizenship-based approach to care that decouples it from individualistic and paternalistic paradigms that disempower those who give and receive care”.

The review looks at the move from the conceptualisation of care as a labour of love, to a commodified activity (paid labour). It considers the difficulties in understanding it as having a “moral value, comparable with justice” and at the same time “giving it an economic value “ and marketising it.

The nature of care is explored as an emotional disposition towards others where “empathy and the recognition that the condition of another is important and that this involves both an interest in their life and a degree of responsibility for their well-being is fundamental to what we consider to be care”. It involves close physical contact and is a social relationship involving power and dependency. The carer and the cared-for are dependent on one another. There is a right to “have the giving of care recognized and legitimated, and the recognition of the right to receive care and support”. This is an issue of justice for both as well as the development of identity.

Care has come to mean “not caring about someone but caring for in the sense of taking responsibility for”. This leads to “the perception of disabled people as powerless”. But ”caring relationships are often complex, reciprocal and mutually supportive” and so interdependent - providing “choice and control for both parties”. The process of commodifying care places both at risk of market failure.

Care is “simultaneously emotion and labour and relationship - - for paid and unpaid carers, as well as for those receiving care”. Motivation for carers is principally emotional and so “caring about”. This cannot be bought or forced so is not easily marketised and when it is it readily becomes caring for, which is “mechanistic at best, and abusive at worst”. “Access to care, and the giving of care - - are important - - for social participation” an aspect of citizenship. Understandably, “who provides and funds long-term care is fast becoming one of the most contentious contemporary political and social policy issues”.

In spite of all this uncertainty there has been “no systematic body of evidence gathered to compare the different types of care regime to establish whether some types are better than others”. “Economics has long ignored the phenomenon of care” which is difficult to measure. The two are separate worlds without a theory that brings them together so that the “marketized vision of citizenship does not necessarily represent unmitigated good news for the social participation and self-determination of carers and cared-for”. Wages and conditions for care workers are likely to suffer with consequences for social participation by both underpaid and undervalued care workers and for the care users that depend on them placing them at “significant risk of exploitative, low-quality care that fails to meet their needs at best, and is abusive at worst”.

The authors argue that “care needs to be reframed within a discourse of citizenship, rather than markets, for it to become a means of self-determination and social participation for both carers and cared-for”. Marketisation is not the only way of providing choice.

Employment and Informal Care: Sustaining Paid Work and Caregiving in Community and Home-based Care Michael D Fine.  Ageing Int (2012) 37:57–68 DOI 10.1007/s12126-011-9137-9

This paper examines employed and informal care in the community. It notes that “care is essential for life, but it no longer fits into contemporary social life as it did in the past”. Yet “informal care provides the often hidden foundations of policies promoting care in the community and Ageing in Place”. Informal care provided at home is “the main source of support for most older people needing assistance”. The paper examines the “current impasse” for carers who work and seeks ways of resolving the “existing conflict between sustaining employment and providing informal care in the home “ and so “re-embed care in the societies of the 21st century”.

The issues are a consequence of “the transformation brought about as social change by forces that are historically unprecedented” – extended life and reduced birth rates. There are fewer to care and more to be cared for. This is accompanied by economic changes and a changed labour force that is faced by longer hours, greater demands and less pay. It is casualised, insecure and exploitative especially for migrant workers.

The bulk of care is still provided by partners and daughters who also have jobs. Demands on all carers are often “far more complex than was considered acceptable in the past”. Services “complement and help sustain, rather than replace, family care,” particularly during crises. Woman rather than men bear the brunt of the care and there is a striking “income penalty paid by care givers”. Twenty years of neoliberal market solutions with the state reducing its role and placing the onus on families and the market has not resolved the problem of finding adequate funding so that “uncertainty and insecurity is the impression that lasts”.

When care failed in the past transfer of responsibility for care was total. What works best now “is both together. Shared responsibility”. The “intimate personal meanings of lives intertwined by kinship, marriage and love need no longer be drained by requiring total self-sacrifice”. We can “adopt new approaches that can enable family caregivers of older people to sustain employment and career”. Much can be achieved by breaking down “the dichotomy between paid employment and informal care”.

The paper does not offer solutions but suggests that strategies might include paid and unpaid leave and temporary part time work patterns, a care friendly workplace, increased access to services able to respond rapidly to short term needs for support, care payments to those who stay at home to care, exploring the potential of technology, and finding ways of addressing the workforce shortage. Maintaining employment “must no longer be seen as competing with the needs for care”. Other papers have suggested coopting and training healthy retirees to the workforce as part of a community reciprocity program.

 Individualising care. The transformation of personal support in old age Michael D Fine. Ageing & Society 2012 doi:10.1017/S0144686X11001310

In an important paper Fine examines the profound changes that have been occurring in aged care and in society and their impact on one another. These changes are ongoing and incomplete. In society itself many social structures including the family have been breaking up and new structures are forming. Rather than being seen as part of a family or social group people are “seen and held accountable as social beings in their own right”. We have adopted a more “ego-focused individual identity” with a shift in the We-I balance.

The focus is on the individual rather than family or local community. Women are most affected as they have moved from the home into employment. Within this change there is the promise of the “recognition of new forms of re-embedding through social recognition of individualised identity and (then) personal commitments as a second step.” He suggests how this could be accomplished.

The paper analyses the concepts of individualism when contrasted with altruism and how these ideas have changed as they have been attached to competition and gender. Recipients of care have shifted from patients, then citizens and clients and now to consumers. Care moved from the home into regimented institutions where individuality and identity were lost. The move back to community is part of a process (ideas of citizenship and personalisation) of recognising and restoring individuality and identity to those needing care by placing them at the centre of the process.

Fine argues that care, whether from family or employed service is essentially a relationship where both have individuality and identity, where both have rights and responsibilities and within which both build identity. It is a reciprocal relationship where family providers need support from formal providers to make it sustainable for them. Power within the relationship is negotiated. That sharing of care should extend into residential care in order to preserve the relationship. This is a public issue and care as a relationship should be recognised in civil society and in law.

Fine is very critical of the neoliberal policy which “re-expresses individualisation as a form of ‘consumer choice’” and does not recognise the “full person”. “‘Tailor-made finance’ is not the same as ‘tailor-made care’”. He goes on to show how the liberal agenda clashes with care as a relationship and makes it very difficult to attain. He targets the exploitation of the workers in the sector as a major impediment to the building of relationships. The idea of individualism is “often abused in its reduction - - - to market-based consumer choice and in the hidden exploitative approach to care workers and unpaid care-givers”.

This is a complex but very insightful paper and it is impossible do it justice in a brief summary.

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Fine 2013 and 2014

2013/14

‘Ageism, Envy and Fear. The Contradictory Politics of the Sequestration of Old Age in the 21st Century’ byFine, M.D. (2014 in G. Poiner (Ed) People Like Us: The Politics of Difference, Independent Scholar Association of Australia (ISAA) NSW Chapter Canberra.

In this chapter from a book Fine examines ageing and ageism starting with the definition and sequestration of older people as “other”, the reasons for this and the way this allows younger generations to distance themselves from their own future. He criticises the economists attempt to increase the age of retirement in societies where employment is decreasing and there is resistance to employing older citizens.

He describes the negativity that has been directed at the ageing of the population – an economic burden, a threat to military and workforce manpower and so economic performance - changing social and economic life – threatening younger generations etc. The various social and political attitudes are explored and analysed.
Some see this negativity as a consequence of the way “economic investment treats the workforce as ‘human capital’” and “older people are regarded as poor investments”. The “problem” can be seen as a consequence of the success of capitalism in improving life and increasing longevity.

Fine ends by taking a more optimistic view indicating that “the extra years are producing opportunities for meaningful social engagement and personal development”. Simplistic solutions “such as privatising all social provisions” are unlikely to work but there are other strategies available which will ensure that older people have a place in society.

Ageism, Envy and Fear :The contradictory politics of the sequestration of old age in 21st Century Australia. Powerpoint presentation by Michael Fine Macquarie University.

A Powerpoint presentation with the same title covers much the same ground and it is publicly available.

Re-Thinking Care for the 21st Century Presented at Carers NSW Annual Conference, March 2013 Powerpoint presentation

The slides in another Powerpoint presentation in 2013 summarise many of Fine’s arguments.  He argues for building “a more complex, a more inspiring view of care as an essential, core part of our lives” moving from “a burden of care to a culture of care”. After reviewing the demographics of care he posits it as a series of societal rights to both give and receive. He concludes that “Giving care must be seen as an important part of what a good life involves, an opportunity for genuine personal engagement and self-realisation of a type that much other work in this digital and impersonal age can never hope to provide”.

Intergenerational Perspectives on Ageing, Economics and Globalisation Fine, M. (2014) Australasian Journal on Ageing, 33(4): 220-225.

This article also explores the negative frames of discourse that have characterised what Fine calls ‘Apocalyptic Economics’? While economic changes have created the aged care problem, the sector now sees it as a “source and leading indicator of social and economic deterioration”. This has become “a form of self- evident common sense”. They worry about the “economic impacts of sustaining large and non-productive surplus populations”. It is seen to threaten subsequent generations. There have been strong arguments for cutting social spending.

The article suggests that the various “current approaches each demonstrate significant limitations”. The issues are far more complex and “one dimensional analyses that see ageing simply as a cost obscure and confuse our understanding of the challenges of adapting to an unprecedented demography in which old age will become more common place than ever before”. Voters “make political choices on the basis of complex social affiliations and lifelong identities”. They “do not simply act selfishly”.

Nurturing longevity: Sociological constructions of ageing, care and the body Michael Fine Health Sociology Review (2014) 23(1): 33–42.

Fine writes about the physical contact involved in care and the emotional and relational aspects of this. He reviews what happened when women moved out of the home and care moved into institutions. It has now moved back into homes where it has to compete with the demands and stresses of working men and women. He is critical of the limitations of theories, which have focused only on the viability of providing formal support systems, claiming that many “fundamental questions remain beyond the horizon of this debate”.

There has been “little analysis given to the questions of informal care” and debate “ignores the visceral reality of the body” the causes of disability. He looks at how the subjective experience of disability has been disregarded even by advocates for the disabled who have adopted a market orientation. They have tried to “invert the relations of power” by making the disabled the employer. They have developed programs like Consumer Directed Care, which pursue the ideal of consumer sovereignty. Care is reduced to something “less emotive” and simply “cold, hard, support”.

Our perceptions of body and disability are social constructs but the body also “has a materiality, a visceral, biologically based physical presence absent in purely symbolic social phenomena”. This “over-constructed life” must be corrected by a recognition of the body as a “physical reality” that is “central to biological life”. There are limits to the social constructivist’s approach. The argument brings us back to the centrality of active relationships in that care involves intimate and very personal bodily contact between two different bodies – “a bodily engagement in two senses”. It is emotional and personal. Unlike other work there is an additional closely linked dimension of “emotional labour”. Care-giving can be both physically and emotionally draining”.

Touch is a fundamental and this is linked to our social response. A recognition of the recipients selfness is essential in caring for their bodies and its absence is readily apparent in the way task focused care is provided. When the mind is lost as in Alzheimers then “care is often no more than a polite word used to describe management of the problem”. Fine returns to “an understanding of care as a ‘relationship-based’ activity”.

{Note: Fine fails to explore the formation of relationships when the mind of one party is already lost when first contact is made and the person cared for is little more than an impersonal body. But for family the relationship still exists through memory and close ties. I would argue that a close relationship between family and formal carers allows for a vicarious relationship through association and story-telling and that the formal carer can continue to ‘care about’ the body by sharing in that relationship with family - an argument for the continuity of shared care in nursing homes.}

Fine returns to community care because the bulk of care is given informally in people’s homes and most elderly want to stay there and be as independent as possible. When this becomes impossible at home then care is “negotiated between care recipients and family members” with resort to formal care when this becomes too burdensome. As a relationship care shapes the lives of both those who receive and those who give it. Formal care becomes critically important in supporting and enabling this relationship but does not replace it.

Economic Restructuring and the Caring Society. Changing the Face of Age Care Work by Fine, M. (2014), Soziale Welt, Sonderband 20, B. Aulenbacher, B Riegraf, H Theobald (Eds): pp269-278

The abstract of this article indicates that it “explores the outcomes of the interaction of social and economic pressures on the way that care is conceptualised and provided - -. Three key social-economic factors are identified as increasingly important in setting constraints on the options for its further development: the characteristics of care as a form of personal service; the cost issues associated with financing social policies for an ageing population; economic developments on a global scale used to justify increasingly sharp divisions between professional managerial staff and the larger care workforce which is increasingly insecure and treated as disposable”.

The article looks at the way the recent “restructuring of the labour market and welfare state” under neoliberal influence interacts “with new social demands for changes in our work lives, (as well as) our intimate relationships and personal lives”. The interpersonal relationship that aged care really is has been “shaped on the outside as an occupational category” and unpaid care at home is “subject to the same pressures” as work elsewhere. Work and care are not seen as mutually exclusive and carers are expected to do both.

But the “productivity growth in services” expected under this restructuring is not attainable because the amount of care per worker is severely constrained. Twentieth century hopes for technological changes that would see the end of work have been dashed by an “increasingly globalized, dynamic, but unstable and segmented labour market”. Particularly concerning is the adverse consequence this has had on the labour force in aged care – mostly “women, the high proportion of part-time and casual work”. There is a “‘wage penalty’ for working in care occupations” - called the “compassion trap”.

In addition “substitution strategies” have moved care recipients from “costly, high intensity services to more affordable, lower intensity services” as well as from public responsibility to market. Both are “run like businesses on principles of market competition” raising “the spectre of a future of McDonaldized style care” with the same sort of labour force. There are “pressures to reduce costs by reconfiguring care work - - (and assigning it to) - - members of the globalized disposable workforce”. “Corporate and managerial power has increased” and professional influence “is increasingly threatened”. “Those whose interest is a professional concern for their charges increasingly find themselves in conflict with those whose interest is principally financial”

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Fine 2015

2015

Eva Fedor Kittay: Dependency Work and the Social Division of Care by Fine, Michael D. (2015), in Fran Collyer (ed) The Palgrave Handbook of Social Theory in Health, Illness and Medicine, Palgrave, Basingstoke UK: 628-643

In this article Fine examines the work of US feminist philosopher, Kittay, in order to explore the nature of power in the relationship between carer and cared for. Kittay herself had a child who was severely handicapped from birth. Kittay writes from a theoretical as well as a profoundly personal experience.

As background Fine reviews the many ways care, “a remarkably slippery concept” has been understood. Relevant here is whether care is seen as the “property or virtue of a particular group, or broadly as a widespread and necessary ‘species activity’”. The ideas are not incompatible with one another. Fine comes back to the argument that “caring relationships are often complex, reciprocal and mutually supportive.” He examines the way Kittay’s analysis of power adds flesh to these arguments.

In her work Kittay drew a distinction between power, which could or could not be exercised and dominance which was the abusive use of power. Kittay’s contribution to this debate lies in her understanding of “dependency as a fundamental part of, and condition for, human existence” – something we all go through. She argues that feminism has not brought equality because the “invisible impact of dependency has led to equality eluding caregivers, and by extension, women who selflessly assume it”.

Kittay analyses “dependency workers” and their “charges” in terms of power in relationships. The dependency worker does not exercise the power inherent in dependency relationships “unless it is for the charge’s benefit”. But in many situations the charge also has power “as a result of social position, wealth or control of employment”. So “a successful care relationship is built on mutual trust and responsibility”. Domination is an illegitimate exercise of power and it can occur “when either the worker or the charge abuses this trust”. The “ties of duty, of identification with the other and the sense of self-sacrifice formed through the recipients dependence” create a situation that can be exploited by the charge to tyrannise the worker.

Kittay’s argues that there is “a second, socially createlevel of dependency” for the worker because in the welfare state she is an employee reliant on a provider for support. This secondary dependency “can be described in terms of her bargaining position in respect to the provider” and this will impact on her ability to meet her commitments to her charge.

Recognising these ‘nested dependencies’ brings the argument back to care as being an integral part of society. Kittay argues for a ‘public ethic of care’ in order to “overcome the disadvantage and limited autonomy experienced by those who take on responsibility for the support of those who are dependent”. As citizens in a democracy we should be able to receive care without those who give it being penalised. Dependency should be at the centre of concerns for justice.

Our dependency takes this “goes beyond the liberal conception of equality which eschews dependency and relies on a notion of reciprocal recognition extended between reasonable and rational adults”. This brings us back to Fine’s concern about the plight of aged care workers in the real world where people are dependent on one another and not equal. There are systems that use this power to dominate and so “penalise and exploit those who provide care”.

Cultures of Care by Fine, Michael (2015) in J. Twigg and W. Martin (eds) Routledge Handbook of Cultural Gerontology, Routledge: Abingdon UK: 269-276

The abstract of this paper indicates that the concept of cultures of care covers three distinct but inter-related domains: i. the ideals and approaches to care associated with different traditions, national cultures and ethnic groups; ii. the practices and values associated with particular work places, organisations and professions; and iii. the care practices, values and behaviour produced as a response to national welfare and labour market regimes.

“Implicit in the use of the term cultures of care” is recognition of the complexities created by the concepts of ‘caring for’ and ‘caring about’ on the one hand and the ‘informal and formal’ provision of care on the other. This is especially so when seen within the context of welfare capitalism. Key dimensions of difference suggested are ‘warm and cold’, ‘traditional and modern’, and ‘family or social responsibility’.

Using these dimensions care can be conceptualised as warm traditional, cold modern, warm modern and cold postmodern. What varies in these ideas is the ‘value placed on care’ and the way features in “competing and overlapping cultural ideals” invoke “different senses of personal identity, responsibility and entitlement” which in turn play out in actions and behaviours.

The paper then considers major theories and approaches which Fine has written about in other articles within the frames of a ‘feminist’ issue, the ‘ethics of care’, ‘gender, rights and the receipt of care’, and ‘Medical Anthropology’.

This is followed by an examination of the way these cultures of care are shaped and transmitted. The discussion of shaping commences with the appropriation of professional cultures by management.  The article uses the example of nurses whose professional culture of caring is acquired through education and work practices. A contrasting culture of care comes from the application of the concept of culture “by experts from organizational, management, and business studies fields - -(creating) - a conflict between the cultures of ‘hi-tech’ and ‘high touch’ care orientations”.

The second shaping is through gender issues because women assume responsibility for care although increasingly male partners and sometimes sons become informal carers. The elderly turn to informal carers (usually female) and formal care usually supplements this when informal carers struggle.

While women still dominate “this has become more flexible and is open nowadays to negotiation”. A study of three countries revealed the way carers in each negotiated the restrictions they faced and managed the formal and informal resources available to them. The way they adapted illustrates that care culture must be seen not simply as “a traditional pattern but as a creative and living production”. Cultures of care cannot be simply “reduced to financial incentives and labour market opportunities – - traditional cultural values and ‘care ideals’ are deeply linked to a sense of personal identity”.

Fine finishes by commenting that “the richness of academic discussion on the topic stands in contrast to its limited use in policy” and by pressing for a “deeper examination of the male resistance to taking greater responsibilities for care”.

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Davidson 2008 to 2011

2008

NON-PROFIT ORGANISATIONS IN THE HUMAN SERVICES MARKETPLACE: THE IMPACT OF QUASI VOUCHER-LICENSING SYSTEMS by Bob Davidson Paper presented at 37th Annual Conference
Association for Research on Nonprofit Organisations and Voluntary Action Philadelphia November 20, 2008

This presentation looks at human services and the different ways managed markets (ie funding provided by government) operate and the implications for the Nonprofit sector. The funding systems are contracting, quasi voucher-licensing (QVL) and hybrid systems. The focus is on QVL “whereby each eligible user of a service has an individualised subsidy from government and they (or their agent) can choose their own provider from a set of approved (or ‘licensed’) organisations”. Government pays ‘a subsidy for each individual approved user’”, and the user (or their agent) can choose their own provider from a list of providers approved by government so it operates more like a conventional market. Viability depends more on assessments made by the user so provides less certainty but more opportunity. (eg Medicare and aged care)

The paper explores complex issues in depth looking at pluses and minuses and some implications. Only a few points will be noted here including that.

•  “Government has the power to shape both the services and the markets” and can “directly control both who comes into the market” and “many aspects of how they operate”.
• There may be “blurring of boundaries between NPOs and FPOs and mission drift as NPOs move away from their original purpose and are perceived to operate more like FPOs or their funders”.
• Lack of adequate information allows more scope for attractive marketing that does not reflect quality.
• It also allows creaming or stratifying of services where providers select to serve only those that are wealthy and can pay large copayments so skewing the service.

The impact on Nonprofits are reviewed and the multiple factors that impact on whether for-profits will replace them or whether they will survive are discussed and what opportunities there will be for them.

One factor is their contribution to social capital and to advocacy on behalf of their communities. He quotes other researchers who consider that there is a “bleak picture for the generation of social capital” by “strongly encouraging the business model of management”. Those “few non-profits which attempt to operate by a civil society model are particularly disadvantaged in the market-type environment”. Some are worried that the blurring of boundaries may threaten the future of civil society.

There also seems to have been a shift “from advocacy on behalf of clients to organisational self-interest” and “governments may stifle advocacy by the conditions it places in contracts”. Changes in for-profit and nonprofit activity in residential and community aged care are described.

The conclusions are tentative only. There is a “strong likelihood that FPOs will be more prevalent where QVL operates” but this is likely to be mostly smaller for-profits. It will also create a number of opportunities for non-profits” by finding niches in the market. Nonprofits are likely to get a “smaller share of the cake, but it may be a bigger cake”.

Comment: This assessment was made in 2008. This is the optimistic attitude taken by Australian nonprofit residential care owners who claim they can survive, but some have already elected to vacate the sector. Since 2008 government have funded and supported rapid consolidation, particularly in residential care, with the growth of large private for-profit groups, market listed groups and private equity groups whose high risk profit policies have rapidly altered the scene in residential care.

I have closely examined what happened in the USA in health and aged care when the same thing happened and am far more pessimistic. Nonprofits did survive but largely by behaving like big for-profits and the same is increasingly happening in Australia although they strongly deny this. I explore this on other pages on this web site. Whether this will continue despite a recent share market setback will probably depend on the sort of government we get. In his later 2015 paper on community aged care (see below) Davidson asks why this sector has remained largely nonprofit when other sectors including residential care have become increasingly dominated by for-profits.  This seems to be an acknowledgement that it has been happening despite his predictions in 2008.

2009

For-profit organisations in managed markets for human services by Bob Davidson in Paid Care in Australia: Politics, Profits, Practices (2009) Edited by Debra King and Gabrielle Meagher Sydney University Press ISBN: 9781920899295

This chapter sets aside the question of “the validity of marketising human services” and assumes that government is going to continue doing it. To date they have developed managed markets where government pays and there is competition for funding. The article analyses the nature of managed markets in depth and the greater number of for-profit providers this brings. It recognises and describes the risk of the prioritising of profit over care but correctly debunks the idea that all for profits behave in this way. It is a diverse group and many are motivated by an ethic of service. The article also notes the blurring of the distinctions between nonprofits and for-profits that I describe on these web pages.

Davidson stresses the importance of closely monitoring the initial entry into the sector because of the inherent tension between profit and care as well as the “lack of perfect information for service users”. While there may be a “need to limit the entry of certain providers in some situations” for-profits differ and the focus should be on the behaviours of providers and on a number of factors described in the chapter.

Comment: The word probity is not used in the article but this seems to be what would be assessed here. What he proposes is totally different to what we have in aged care. The Howard government removed the probity requirements in aged care1997 and the conduct of owners was declared irrelevant. Provided an entrant to the market is buying an existing business it does not have to seek approval at all.

The other problem is that you only need one provider, particularly a large one to gain a significant advantage and threaten the viability of others by unethical or exploitative practices to destoy the ethic of the whole system.  To compete the other providers have no choice but to follow.  This happened in the USA and in the Job market in Australia.

2011

Contestability in Human Services Markets By Davidson, Bob Journal of Australian Political Economy Nu 68 Summer 2011 Abstract only seen 

Neoliberals see contestability as the answer to the problem they see in government monopolies and their relationship with ‘in-groups’ usually inefficient non-profits. Recently “user choice” has been used to justify the use of market mechanisms. The paper explores these issues.

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Davidson 2013 to 2015

2013

Building an Industry of Choice: Service Quality, Workforce Capacity and Consumer-Centred Funding in Disability Care (Final Report for United Voice, Australian Services Union, and Health and Community Services Union) by Natasha Cortis, Gabrielle Meagher, Sharni Chan, Bob Davidson & Toby Fattore SPRC (Social Policy Research Centre) March 2013 

This multi-author study addresses disability services and the NDIS but the similarities with aged care make the findings relevant for Consumer Directed Care in aged care. The study looks at the plans to introduce “market-based funding models within which ‘choice’ and ‘control’ are key principles”. There are a range of consumer centred funding models including allocations of funds which are portable between providers, and self-managed, personal or individual budgets. Variants have been trialled in Australia and the UK has introduced its own models.

This report is concerned about the impact this might have on disability service workers and their capacity to provide the high quality services that are required and planned for the sector. The NDIS program starts with a work force that is already casualised, overworked, underpaid and depleted and success will depend on them. The lowest wages are in the non-government sector. This is largely the effect of outsourcing, yet this is the sector that policy for the NDIS is focusing on.

The report looks at the pluses and minuses for both staff and residents of the various options. Even though trials have been done evaluation is limited and the focus has been on those purchasing care rather than staff. Assessments are based on limited studies. The paper reviews experience in England, West Australia and Victoria.

There are pluses and negatives for most of the proposals and the article explores them in depth. In general those consumers who opted to take control and employ individual assistance were professionals with experience. Many, particularly the elderly, found doing this complex and daunting. Being in control was positive for those with the capacity and the care they were given was what they wanted. Some employees preferred the independence of contracting directly with the person requiring care. There were however a number of risks to this arrangement and some advantages to using organisations that employed staff.

The study concluded that significant resources would be needed to maintain staffing and skills. Higher costs in the short term would pay off in sustainability and better services in the long term. Simply handing control of money to the person with disability created risks for them and for those they employed and it would be difficult to monitor. “Voice and choice - - can be developed in collaborative arrangements within service organisations”.

2015

Community aged care providers in a competitive environment: Past, present and future, by Davidson, B. 2015, in ‘Markets, rights and power in Australian social policy’, eds
G. Meagher & S. Goodwin, Sydney University Press, Sydney.

Davidson has written an excellent review of Community Aged Care (“a diverse and complex industry”) in Australia. He highlighted the desire of the elderly to stay at home, the projected growth and massive changes expected in the sector as well as the threats of the neoliberal agenda (profit maximisers rather than social maximisers) to the sort of care provided.

This is an analysis of why Community Aged Care in Australia has remained largely nonprofit in the face of increasing user payment and “the expectations created by neoliberalism and marketization”, whereas in other countries and in other Australian sectors like child care and residential care there has been a significant influx and often major takeover by for-profit providers. He refers to “the extensive growth of FPOs, the reduction of the role of NPOs and the end of the substantial involvement of government providers” in most similar sectors.

The government contracting system has in the past favoured and so resulted in an increasing number of large nonprofits which have corporatised and organised themselves so that they are more efficient in obtaining contracts and more competitive. They are able to hold their own. In contrast for-profits in the sector are small or middle sized and not large or market listed.

Davidson describes many other factors in the managed markets that have developed as favouring the nonprofits but particularly their long incumbency and established position in the sector. They have had “space to develop as large and efficient operators now able to successfully compete.” He also acknowledges that “there is scope for opportunist providers that are profit maximisers rather than social maximisers to reduce the quality and equity of services”. He identifies franchising as one possibility. Further changes not yet considered might “lead to more FPOs (for-profit operators) and a greater market share for FPOs”.

He predicts that Non-profits will remain dominant in the sector and points to the Job Network as an example where this has happened. He concludes that “large NPOs are likely to retain their prominent position”. There will be an increase in for-profits, greater concentration of market share with more large for-profits, and “a reduced market share and uncertain future for small community-based NPOs”. He warns of the risks of going “too far down the marketisation track.”

Comment: This is an excellent review but I wonder if it is not too optimistic. There are other factors and other risks. I suspect that while it was published in a book in 2015 it was actually written before 2014, before the Abbott governments changes and before several scandals involving nonprofits.

1. Change in nonprofit’s behaviour with neoliberal policies: The sector is being made increasingly commercially competitive. As is illustrated in residential care, nonprofit providers respond to this situation by behaving like for-profits. This has the same consequences. Even a small number of for-profits who seize an opportunity to exploit those they are responsible for to gain a competitive advantage can force nonprofits to compete. The Job Network used as an example to support Davidson’s argument is a prime example of this. There have been massive scandals and some nonprofits have joined in this.
   
   
2. Patterns of relationships: When I studied sociology many years ago the patterns of informal relationships that develop within and between all organisations were considered to be very important in making decisions and policy. They seem to have dropped out of sociological studies but Briathwaite describes how informal relationships made dysfunctional government regulation work in aged care. Informal relationships are usually beneficial but they can sometimes provide the mechanism for fraud and exploitation. The social context can be important in this.
   
   The way in which these networks of relationships in federal health and aged care departments extent across into large and successful for-profit providers in the residential sector is readily apparent. It is likely that similar informal structures within state departments extended into the successful nonprofit providers in much the same. They would have been much more aware of the risks of marketisation in this much more vulnerable and difficult to regulate sector. This would help to explain why state bureaucracies favoured large nonprofits in awarding contracts. Federal departments are more likely to take the opposite approach.
   
   
3. A delay in prosecuting neoliberal policy: The Howard government’s neoliberal policies in community aged care were relatively low key. Their residential care policies had created a massive backlash in the community which took time to subside. In health care it was engaged in a bitter dispute with doctors which it lost. There were large scandals in aged care so policy was directed to containment and denial. This has now changed.  They are noe "reforming aged care" within a neoliberal agenda.
   
   
4. Risks to Commonwealth control: There are risks to the transfer of control of all aged care to the Commonwealth and the removal of the restraints created by the states. This is well illustrated in residential care and by the ideological Abbott government’s brief period in office.
   
   There was considerable additional liberalisation of the sector when Consumer Directed Care was introduced. Abbott promised and gave additional funding to foster consolidation which he encouraged. Some aggressive global franchising companies seized the opportunity Abbotts public statements promised them. They announced their entry into Australia and some like this one started advertising for untrained staff whom they indicated they would prefer to train themselves.
   
   We have heard less and less of all this as the community backlash against Abbotts’ government grew and his re-election prospects fell. The more moderate Turnbull government did some backtracking as revealed by its attack on corporate maximising and then its cuts to aged care funding. Perhaps community care has had a lucky escape!
   
   
5. Risks in the future: In the post-truth era there must be a considerable risk that an extreme neoliberal faction will regain control and we may not be so lucky again.

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Davidson 2016

2016

Marketisation and human services providers: an industry study Bob Davidson Chapter 18 Handbook of Research Methods and Applications in Heterodox Economics Edited by Frederic S. Lee and Bruce Cronin Bruce Cronin April 2016 Brief Abstract only seen

This book is about alternate methods of studying difficult areas. The abstract I have seen indicates that there “is substantial inherent market failure” in human service products. This “has major implications for the structure and operation of markets”. The study looks at the methods used to study this in home care for older people. It will be interesting to see what this research revealed.

Submission PFR354 to the PRODUCTIVITY COMMISSION INQUIRY into HUMAN SERVICES Dr Bob Davidson October 2016

Davidson was unable to make a full submission to this inquiry for personal reasons. He wrote a short response to criticise the position taken by the commission’s preliminary findings report and to correct sections where he was incorrectly quoted in the report.

He indicated that “using market mechanisms in the provision of human services is a more complex and problematic task than has been presented in the two papers distributed by the Inquiry”. He indicated that while each case is different “in general there are tight natural limits to the use of markets in human services. This is clear from both well- established mainstream economic and organisational theory, and from the very real problems that have emerged with using markets in human services across many nations and services over the last thirty years”.

He indicated that there was little acknowledgement of the “extent and depth of both the natural limits and the extensive problems that have occurred” and then again that the report “does not adequately acknowledge the reality of markets in the special case when a human service is the product”.

He acknowledges that there are situations where market measures can improve services rather than harm them but these are “obtained when there are limits - sometimes significant - in the use of these mechanisms”. He argues that “both theory and empirical experience clearly show that the limits to what is possible are much tighter than what has thus far been acknowledged in the two papers from the Inquiry’. He promised a more detailed submission on these issues but if submitted it has not yet been published.

Comment: I agree with these comments. While never perfect markets operated in human services long before the neoliberals made them policy. They were controlled and directed by the social structures and interpersonal relationships of a civil society whose values and norms set the limits of acceptable conduct. These were supported by democratic governments which at that time represented and served citizens rather than ideologies. They introduced regulations like probity requirements.

Neoliberal governments abolished these laws and took control of civil society and its thinking in what I argue is a reversal of the traditional view of markets being required to serve the community. Instead civil society has to a significant extent been restructured to serve markets.

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Other authors 2002 to 2017

2002

SOCIO-ECONOMIC IMPACT OF SOCIAL TIES ON COMMUNITY CARE FOR OLDER AUSTRALIANS (2002) Discussion Paper No 312 by Vecchio N and Jackson S August from school of Accounting and Finance at Griffiths Univ. and School of Economics at Univ. of Queensland 

This paper examines the impact of social isolation on the care of the elderly and their need for services. Government policy in 2002 was to depend on greater self-reliance and greater user payments. Social relationships have a powerful effect on physical health. Social isolation is associated with increased rates of suicide and with increased mortality from most causes. Men are more likely to be isolated. They have greater rates of suicide.

The literature was reviewed and a survey of elderly residents on the Gold Coast was carried out. They found that

• men living alone were more socially isolated from family and friends than women who maintained family contact and more readily formed relationships,
• those living alone and those who are better educated are likely to meet family less often,
• those living alone experience less contact with family than couples,
• 30% of single men admitted to loneliness compared with 18% of women,
• single males were reluctant to accept help – a culture of independence among males,
• as a consequence older males are more vulnerable than older females to the social network effects of living alone, and
• there was general satisfaction of health services (HACC) reported by the survey respondents

The authors were worried by “the current political environment of cost cutting and notions of self-reliance” and a system that was “increasingly reliant on the informal support provided by friends and family,” something that was not available to many. They advised close monitoring of vulnerable groups.

2009

Caring for profit? The impact of for-profit providers on the quality of employment in paid care by Debra King and Bill Martin in Paid Care in Australia: Politics, Profits, Practices 2009, Edited by Debra King and Gabrielle Meagher Sydney University Press
ISBN: 9781920899295

This is an interesting paper from a group at Flinders university. It challenges our and many other’s views of the performance of for-profits and not-for-profits when it comes to staffing. They indicate the “money versus care argument is typically applied at the level of careworkers”. The research is based on a government “census of all residential aged care facilities across Australia, and a random survey of employees in these facilities”. The findings and comments of others are challenged.

They found that “for-profit facilities operate with somewhat leaner resident/staff ratios than others, but that they compensate for this by having staff spend more of their time providing direct care.

The findings were that the differences in staffing levels between the different types of ownership were quite small and “do not translate into differences in the subjective experience of work” and the “impact of cost pressures on care provision occurred across all three modes of ownership”.

They also discussed the extent to which “‘institutional isomorphism’—a tendency for organisations in a given ‘field’ to look very similar, irrespective of differences such as those of ownership” might be playing a part.

Comment: These findings differ from the feedback that Aged Care Crisis has been receiving over the years although we have also seen the nonprofits change the way they operate and this seems to be reflected in the number of failures in care reported in the media and the unhappiness by staff.

I think there are a number of flaws in this paper. First is the absence of any data about the standards of care in these facilities because it is not collected in Australia. The second is the failure to examine the difference between metropolitan and rural services, a variable unique to Australia. The third is the failure to examine the variability in the for-profit sector particularly the performance of market listed and private equity owned facilities, both of which have been shown to have a major impact on staffing. On the other hand smaller privately owned for-profit facilities can sometimes be highly motivated and have very good relations with staff outperforming not-for-profits.

The accreditation agency also regularly produces data that suggests that accreditation performance between for-profit and not-for-profits is identical. But its figures also show that rural and remote facilities perform more poorly. There are a very small number of rural for-profits but a large number of not-for-profits. To perform equally overall not-for-profits must be outperforming for-profits in Metropolitan area quite strongly. This is what Aged Care Crisis found when it examined a subset of the data in 2008. In 2014 Baldwin et al reported research showing that for-profit owned facilities were more than twice as likely to be sanctioned for failures in care than not-for-ptofit facilities when the data was properly evaluated. Their original research is here.

Many studies from the USA have demonstrated very clearly the close relationship between both lower levels of staffing and failures in care when compared with the different focus on profits between types of providers. It is long past time that Australia collected accurate and reliable data about care and staffing and assessed it properly. If we are different from other countries then we need to know why.

Aged Care Crisis November 2016 supplementary submission to the Workforce Inquiry examines the US evidence showing the adverse impact on staffing and performance as well as the minimum levels of staffing required to provide acceptable levels of care. It documents the serious understaffing in Australia when compared with the USA, particularly in trained and registered nurses.

• Aged care Crisis Supplementary submission number 302.2 on 28 November 2016 to Inquiry Future of Australia’s aged care sector workforce  by the Senate Standing Committee on Community Affairs 

The across the board understaffing documented in Australia when compared with the USA may well be the primary reason for an ‘institutional isomorphism’ that obscures all other differences. The staffing numbers and differences are so great that there are good grounds for believing that it is not possible for Australians to be getting good care. Until accurate local data is collected there are good reasons for accepting that the many complaints by staff and families are well founded.

2013

Reciprocity: The Case of Aged Care Nurses’ Work Dr Valerie Adams and Professor Rhonda Sharp Research Centre for Gender Studies and the Hawke Research Institute, University of South Australia (Also in Feminist Economics 19(2) · April 2013
DOI: 10.1080/13545701.2013.767982)

This study also looks at dependency relationships in aged care but it does so by focusing on reciprocity. There may be positive or negative reciprocity between individuals but there is also a more general reciprocity which does not require direct reciprocation. This is based on a general value of fairness that underpins care. Our assumption of a general reciprocity within society is the idea that it will come around for us too when needed. Each type of reciprocity is analysed.

The researchers review the literature and closely examine the responses from two studies of nurses. The study shows that reciprocity is very important for staff satisfaction, and for the quality of care. “Care recipient feeling ‘cared about’ and the caregiver deriving satisfaction from knowing that they have provided the caring service well enough for the care recipient to feel cared about”

The article goes on to propose the concept or “professional reciprocity” in which the nurse actively initiates the reciprocal relationships and is trained to do so. These relationships “generate therapeutic outcomes for the caree and greater job satisfaction for the carer”.

Professional reciprocity is severely limited by “time-starved ‘industrialized’ work environments in which ‘care’ degrades to merely a series of coldly executed, standardized tasks”. It requires “both appropriate education and a supportive working environment”.

About half of all nurses thought they were “poorly remunerated with a heavy workload”. They struggled “with the everyday, relentless demands - - no signs of abating”. Time was important for nurses work and “too little time was the main source of job dissatisfaction”.

They conclude that professional reciprocity is part of a complex array of factors impacting on nurse satisfaction and on care. These include “motivation to care, the work to establish and maintain the caring relationship, and the resources (material and time) to provide for and sustain the caring relationship”. While the word ‘neoliberal’ is not used the implications are clear.

2016

SOCIAL SERVICE FUTURES: THE MARKETISATION OF HEALTHCARE SERVICES: WHEN POLITICAL MANTRAS WIN OUT OVER EVIDENCE AND PATIENTS’ NEEDS A Blog by Lesley Russel, Adjunct Associate Professor, Menzies Centre for Health Policy 7 April 2016

This blog is a criticism of the Harper Competition Review and the Neoliberal agenda for health care. Many of the issues it describes for the health system have relevance for aged care.

2017

Are our busy doctors and nurses losing empathy for patients? By Sue Dean The Conversation 13 January 2017

This paper is one of a series of articles on empathy. It quotes from the novel To kill a Mockingbird to make the point that “you never really understand a person until you consider things from his point of view ... until you climb into his skin and walk around in it” and then distinguish that from sympathy. Many of the scandals we see reveal a profound lack of empathy. The articles identifies less touching, computers acting as a barrier, learning through simulations rather than real people, the focus on content and competency in education, multitasking, funding constraints and complexity – all a consequence of the pressures of daily life at work.

Comment:  The caring reciprocal relationships that all of these articles are writing so much about ultimately depends on the ability of carer and recipient to understand one another by climbing into each others skin and walk around in it. Its more than carrying out a task its about being part of the human race.  The argument made on these pages is that the aged care system we have and that our government is determined to refine further is structured in ways that inhibit the empathy, fellow feeling and emotional engagement that builds caring relationships.

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