Introduction: Analysis of the aged care system

Community Aged Care Hub: A brief history

Professor Maddocks looks to the medical profession to lead the way in forming the hub and in coordinating aged care services in each local region. I had earlier proposed something similar by focusing on the community, but both should be involved and it does not matter who leads the way.

In 2006, I wrote about the importance of community involvement in the aged care process. I later discussed this with some community groups who contributed their thoughts.

In 2009 I made submissions to the Review of the Aged Care Complaints system and into the Residential Aged Care Accreditation process. In both, I proposed that their activities should be largely relocated into each community.

In 2010 I made a more detailed submission to the Productivity Commission's Inquiry 'Caring for Older Australians', suggesting how it could be done.

Updating those proposals: In Part 2: A big change to aged care on the Aged Care Crisis website, I brought these ideas together with the suggestions made by Professor Maddocks. In essence, I have proposed a community-based hub comprising medical professionals, community, government and aged care providers. Leadership by the medical profession would be welcomed. They have the expertise.

Additional functions of the hub: My proposals go further than Maddocks. The hub would be the local customer for the services provided to the community, whether they be provided in nursing homes or in the community. In my suggestion, the hub and its central representative body assume oversight and joint responsibility, with government, for the collection and handling of data, complaints handling and for advising and supporting residents and their families.

It is essential that the hub act as a customer (or proxy customer) for vulnerable residents. To be an effective customer they must have the power to insist that the provider gives them what residents, family and the community need and want. For this market, with its undersupply of beds to work effectively, each hub, as customer, should also have a significant say and a right of veto over which owners and providers of aged care they will welcome and support in their communities.

Since writing those pages I have more closely examined the new and planned organisation and structure of the aged care system, which seems to be centrally structured, process driven, complex, impersonal, rigid and contains multiple perverse incentives. It is excessively bureaucratised and not responsive to the needs of the community so that many fall through the cracks.  It frustrates the empathy so important for humanitarian services and provides endless opportunities for enterprising entrepreneurs to game the system in order to maximise profitability. 

I am now suggesting that the hub concept should be extended further.  The administrative and funding process should be regionalised and undertaken by a local partnership between government and community in which government exerts a supervisory and supporting but not directly controlling role.

The linked page below provides additional information about and a brief overview of the content of the Solving Aged Care section on the Aged Care Crisis website and some guidance. You may prefer to visit the ACC site before looking at the rest of this website.

The in-depth detailed analysis that follows on this (Inside Aged Care) website addresses the areas that I suspect are failing as well as areas of potential or possible failure.  It shows how the proposed hub would address the current and potential problems

Learn more: The Community Aged Care Hub

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Comparing the Government’s Aged Care Roadmap with the Community Aged Care Hub Roadmap

In a recent speech the shadow minister for ageing was critical of My Aged Care, the way the Living Longer Living Better LLLB program had been rolled out and of the recently published Aged Care Roadmap.

The shadow minister pointed out that there was a "loss of personal attention and care" and that many did not have the computer and other skills needed to use impersonal service like the Myagedcare system.

But this was his party's program: But the LLLB program was his labor party’s brainchild based on the report of the Productivity Commission Inquiry that his government set up in 2010 to give them the blueprint that they and the industry wanted. He was full of praise for the idea and the program. He blamed the coalition government’s implementation but that is because politicians simply cannot conceive, let alone admit that something they have done is fatally flawed.

A fundamentally flawed concept: In referring to “a loss of personal attention and care" the shadow minister was going directly to one of the fatal flaws in the LLLB program labor designed. What citizens required was a system that actually gave personal attention because this is what people in need require - the human empathic touch and that was lacking from the entire LLLB concept.

Instead the vulnerable and disempowered frail elderly were being offered a highly structured, compllex, process driven, top/down centralised system. The care was delivered by an impersonal unregulated free market underpinned by perverse incentives and driven by competitive pressures to sell the elderly an assortment of profitable choices. Genuine personal attention cannot be provided by a system where “buyer beware” is continuously required and where almost every other free market system where people are vulnerable has seen them exploited for profit.

The LLLB market based system was ill conceived and inappropriate for the sector. It failed to address the fatal flaws that were responsible for the failure of the existing system and the intense unhappiness with it.  As a consequence it has become all about words that do not refer to anything real, or as one critical aged care worker put it "all show and no go".

A response to this flawed system: This web site is a critical examination of this system explaining why it is flawed using examples and quoting what people have said about it. It is not the lofty ideals but the flawed system and the ideas that it is based on that are the problem.

This web site supports an alternate community based roadmap and explains why it has a far better chance of meeting the lofty goals that the Aged Care Roadmap claims it wants but which it is not structured to attain. It is based on a system which at its heart has “personal attention” by real local empathic people whose prime interest is to support the frail elderly and help them to get the most that is possible from their lives.  The market will have little choice but to supply the services that they need and want in order to be profitable.

To set the stage and show the key differences the linked page below contains a table comparing the LLLB program as set out in the Aged Care Roadmap with the sort of community focused roadmap that we at Aged Care Crisis are pressing for and asking for feedback about. This summarises and gives an overview of the two proposals setting out the differences.

Learn more: Aged Care Roadmap

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Perspective and outline of pages

Perspective: My suggestions for a Community Aged Care Hub are based on many years of experience. I have experienced ideologies and have examined market failures in health and aged care. About this site describes my background and approach.

The failures I see in aged care are mirrored by similar failures in almost every sector where customers are similarly vulnerable. Understanding what has been happening in these other sectors is important in understanding the social forces and their consequences.

By looking at what has happened in these sectors, you can understand why I have made the proposals and it will be clear which are the most important in preventing market failure.

Others will see additional benefits, and yet others will see problems. Something needs to be done, so lets look at the issues from different points of view and try to nut out something that has a chance of working.

On this website, I want to:

1. explain the rather different approach I have adopted, one based on my experience;
2. look at what has been happening in aged care when seen in this way;
3. look at the background in the USA and Australia behind the decision to turn health and aged care into competitive markets;
4. look at what has happened in these and other similar sectors;
5. show the thinking I have adopted in suggesting a community aged care hub;
6. show why the changes I am suggesting have a good chance of working.

The section 'Aged Care Analysis' and linked pages within, focus on some broad themes:

1. The application of market forces in vulnerable sectors and addressing that;
2. The risk, possibility, and even probability that what I have called culturopathy is well established in aged care and what can be done about this.
3. That aged care occurs within the context of our society, what is happening there and the political beliefs of the time.

I will illustrate these with real world examples and by refering to the opinions of other critics.

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Being critical

I would like to stress at the outset that this is not an attack or a criticism of those dedicated people who recognise the problems but who continue to do the best they can. They deserve our admiration and gratitude. Without them the system would be much worse than it is today - and I know it could be worse. But it is also clear that it could also be much much better. We need their suggestions and their support.

This is also not a personal attack, or a personal criticism of those who have been persuaded that a free and unregulated market is the best and most effective means of providing care and that our aged care system does so.

The social pressures generated by, and the apparent self-evident nature of dominant belief systems is very persuasive. But I would like you to see it differently and to start talking about it differently. Think, rather than believe, and ask whether credibility is based on fact and logic or on apparent success in one or other sector.  Try to argue against what I have said here and see if it holds up.

Over 200 years ago Adam Smith, the father of economics said that "virtue is more to be feared than vice, because its excesses are not subject to conscience". Virtuous people are far more upset and far more angry when they are challenged and the problem for me is that so many of you are virtuous.

The evidence, and equally disturbing, the refusal to collect it, does not support your belief in what is being done.

Criticising individuals: I do criticise what individuals and companies say and do, but the system and its failures are expressed in the actions and statements of true believers. I cannot criticise the system and illustrate the problems without criticising your actions and statements. I invite you to look at what you say and do, from the point of view of those who are able to look differently from other points of view. 

I also give my interpretation of what you have done or said which clearly may or may not be valid and you may not like, but we need to talk about that if we are going to understand.  Please give your views, explanations and suggestions.  Many points of view are useful.  Ultimately it is society that decides if the arguments are sensible and useful. We need to decide what we think is happening and then move forward from there.

I know many will be challenged and be angry, but if I am going to analyse and vigorously criticise the way people think and what they are doing, then I must look at what they are saying and doing.  It is no good making abstract theoretical arguments.  They must be based on the evidence available. I can only use the information that is available to me and I have selected the things that are being said in the press that help me to make my argument. 

This is a genuine attempt to look at what is happening, look at where it is going wrong and what can be done about it. Please be tolerant and respond by correcting my errors of fact and logic and by contributing to this debate constructively.

To emphasise that it is the system and not individuals that I am looking at I have not used the actual name of the companies and have obscured the name of many but not all  individuals by only using initials.  Those familiar with the events and your companies will know who you are.  The outside web pages linked to will have your names.  Readers need to be able to access this material to assess what I have said. This is a compromise.   I am not trying to hide but to take the emphasis away from the individuals or companies so that they are seen as representative of a particular part of the system.  I don't want it to be personal.

I have explored the problems and difficulties in speaking out, criticising established practices and in making change on a web page on the aged care web site.  Because I am doing that and directly challenging what the market says and believes in on this web site I have put an expanded  copy of that web page on this web site.  It explains both the difficulties in doing this and the importance of doing so.  I discuss the difficulties for the whistleblowers that the public has to rely on for information.  Consider the difficulties for those who see serious problems in the system and look at it from their point of view.  Consider why they are responding and speaking out.

I describe the attempts I have made to address the problem of contested information, unconfirmed comments, and material that has been denied on the Terms of use/Disclaimer section on the website.  As we do not collect reliable information on aged care we have to make do with the best we have and accept that until we have something better. 

You should assume that the quotes that criticise that I use have been said by someone, have been denied by the parties concerned and are generally unresolved.  It is the nature, number and patterns that emerge that I am drawing attention to. There is no way of telling who is correct.  I find them very worrying and my experience is that you don't have smoke without a fire.  With so much smoke, it is likely to be a sizeable fire.

I am not a "determinist". I realise just how resourceful we humans can be when we take off our blinkers, look closely at what is happening, understand the problems we face, and then use our ingenuity and creativity to make things work. Even the most badly thought out systems can be made to work if we identify the key problems and combine to address them effectively.

On the linked page I look at the difficulties in speaking out and challenging others truths and the risk that those who do face.

Learn more: Speak out if you dare

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Markets, politics and democracy

My experience and examination of markets in vulnerable sectors leads me to the conclusion that an unregulated and unstructured free market in vulnerable sectors is fraught with fundamental cultural and personal conflicts that make it a very poor vehicle for supplying care to the vulnerable.

But we are faced by an aged care bulge and it is not the time to change now. Instead, we should examine our current system to identify where the core failures lie, and then try to rearrange the pieces to counter the problems and so make this system work as well as possible.

Risk assessments and politics: In our society we are required to comply with a multitude of governance processes.  Every sports club and almost every other activity is required to prepare complex risk assessments and show that they are taking steps to reduce them. Failures are addressed and learned from.

If you go into hospital and have a surgical procedure, there are a succession of processes and procedures and precautionary measures taken to ensure that any possible risks are recognised and addressed. All participants are encouraged to understand and contribute to the processes. 

Yet political process and government policies avoid this process at all costs. They flagrantly ignore the risks in the policies they impose on us. Any risks, if they do recognise them, are kept close to their chests until they decide to advertise it to the public. Those advertisements seldom mention any risks. 

The web pages I have written can be seen as criticism, but they are also a risk assessment.  The proposed Community Aged Care Hub can be seen as both a risk reduction measure and as a mechanism for identifying risks and then taking steps to address them.

Responses to evidence of failure: Government's responses have been to ignore the core problems. When failures have occurred they have blamed individual failures instead of their own policies and responded by regulating in ways that targeted the offence or the offenders and not the problem. Regulation has been costly, onerous and largely ineffective.

If we look at what has happened in the USA, the UK and Australia it is clear that government regulation is singularly ineffective at addressing systemic dysfunction due to inappropriate social pressures. Look for example at the multiple recent failed markets in Australia. Their misdemeanors and the suffering of the victims have been exposed by whistleblowers and the press.  The regulator ASIC has been singularly ineffective.  When they do identify problems it is too late to prevent them.  Only the excesses and not the basic ongoing problems are identified.  Every now and again there will be more excesses and the process will be repeated.  This is what has happened on a number of occasions in aged care. Any serious solution must start in the community by creating contexts where this will not happen.

We need new ways of thinking about this and new ways of addressing the problems. Good regulations structure sectors by creating contexts that make them work and ensure that they are fully transparent.  In functioning systems, oversight and punitive responses rest lightly and are rarely needed.  Systems that depend on onerous oversight and have to respond to failures by imposing burdensome regulations are not working and need restructuring.

The sort of ideas we need now are not going to come from government, or from those in the industry who are not prepared to confront the failures in what we are doing. We have to decide on the sort of aged care system we want and then make sure we get it.

I hope that those in the industry who see more clearly can bring logic and insight rather than rhetoric and aggression to the debate. This is an issue that sooner or later will impact on every member of society.  It should concern every community. But we, the community, have been sidelined and excluded.

Government has carefully selected those in the community that it is prepared to talk to and ignored the rest of us. They persuade themselves that this is consultation. The rest of us need to debate these issues with you and become participants.

Discussion is long overdue: In 2004 I wrote the following on a web page in which I described the wide disparity in the way the market and the community at risk of exploitation perceived vulnerable sectors like health care, as well as the refusal of the market to debate the issues and look at evidence. Ten years later we are still waiting for the market to look at the evidence and engage with their critics.

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Motivation in aged care

Motivation based on humanitarian values is critically important for this sector. Strong competitive pressures for profit leave little room for humanitarian values.  People who diverge from the primary mission of success in the marketplace are not seen as team players.

If motivation is to be based on humanitarian values then it is essential that the system serves the staff providing care as well as those receiving it. This it is not happening in the current system and we need those providing care at the coalface to come up with their ideas for change.

An attempt to prevent staff from doing so will go directly to the credibility of any company claiming a legitimate interest in the future of aged care and the welfare of the seniors who will be served by it. It is time for change and we need every point of view.

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Why repetition

There is quite a bit of repetition on these web pages. I have also sometimes linked to the same illustrative article from different places, but there are three reasons for this:

1. Firstly, these pages were written as more and more illustrative material became available and so was added and analysed so the same things were sometimes said about it in different places.
2. Secondly, websites are different to other written material because many, even a majority of readers, come to the pages via different entry points, eg, web searches and only read some of the pages - so when writing a web page, you cannot assume that all of the readers have read what you said before. Each needs to be coherent in what it says. I can only ask those who are sufficiently interested to read systematically to be patient and understand the problem.
3. Thirdly, I am targeting a very broad range of people with different degrees of interest, knowledge and willingness to explore in the depth that I have. I am trying to accommodate to this by having a main overview page. This describes the issues and links to pages that explore in greater depth.
   
   When these in depth pages are long or in much greater depth and detail, or where I am exploring from a more theoretical perspective, I have elected to put in an intermediate page. This contains introductory material (eg a theoretical perspective) that applies to several pages and/or an overview of the contents of each more detailed in depth linked page in that section. Most of the many quotes, links and references are in the deepest sections. The detailed arguments are made and expanded there.

The main analysis page gives a broad view of the arguments, but some are brief.  Each of the ticked pages in the side menu is an introductory or overview page with links to more than one in depth analysis.  Linking to those pages provides more depth and a summary of the detailed pages. The unticked pages and the deeper pages contain the full detailed arguments with material and links backing up and supporting the arguments.  This structure allows you to explore the arguments in the depth you need. 

If you are going to comment on or contest an argument, you will need to look at the in-depth page.

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