Aged care consumer reviews

Context: Part of a costly industry supporting the aged care market

The recent rapid marketisation of aged care has created a highly complex centrally controlled system. It is not only complex for the prospective residents and their families but is much more complex for the providers of care, particularly the not for profits.  The market has responded to the opportunities offered by all this complexity.

Serving providers: This complexity has created a whole new industry of consultants and business organisations advising and supporting the providers of care. Not-for-profits are particularly threatened by this marketplace and the need to focus on competition if they want to survive. As described elsewhere, they provide rich pickings for the business consultants.

Serving the community: We have a community of citizens that has largely disengaged from aged care.  Frail seniors and their families, often faced by life changing crises, are presented with an extremely complex system. Complex decisions must often be made with great urgency about finances, contracts and about aged care facilities, all promising them an idealised life on their web sites.  The quality of the elderly's remaining lives and the finances of their families can depend on the decisions made. The information about staffing, standards of care and quality of life that they need is simply not available to anyone.

A second industry of legal, financial and nursing home consultants and advisers has sprung up offering to advise and help prospective residents and their families navigate this system and link them to the providers of care they need.

Serving both: A third industry has sprung up which seeks to collect the opinion of residents, their families and their friends about the facility they use or visit. This industry claims to serve the providers of care by keeping them in touch with the community and enabling them to correct problems and respond to resident and family criticisms. It also aims to serve the community by providing them with the impressions of those who have seen the quality of the services and care provided so that they can make sensible choices when deciding on a nursing home.  In the absence of concrete data, positive reviews can be used to sell facilities to potential residents.

Funding these industries: These three industries are largely funded by the providers of care. Their money all comes from the fees paid by government and by individuals. All of this money is coming out of the funds that we are paying for our care.  There is consequently less for staffing, for food and for basic care.

Where has the money gone?: There was a large injection of funds into aged care under the Living Longer Living Better aged care package in 2014. The confidential Bentley’s report which was recently leaked to the Sydney Morning Herald (Nursing home profits soar as patient care declines - 1 Jan 2016) suggests that the funding spent on care has decreased by 10% since them. Those receiving home care are finding that under Consumer Directed Care they are getting less care for their money. It is clear where all of the money that is not going into the 40% increase in profits revealed by this report is actually going.

Is this an efficient use of funds? Is the community getting any real benefit from it? Is it actually compromising care by underfunding it as funds are diverted to things that now have a greater priority?

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The focus of this web page

This web page focuses on the industry that is collecting feedback from residents (a large number of whom have dementia), their families and their friends. Most have limited experience and are often not well equipped to form opinions. Community input and opinion is valuable and important. But the community do need to be informed to do so effectively.

There has been much talk about educating the community and criticism about the ineffective way it has been done. It is very difficult to educate the uninterested and disengaged. The best way to educate people is to involve them, get them doing things so that it becomes interesting and so that they make a difference. You teach them what they need to know to do that. That is what the proposed hub is intended to do.

Lessons from the past: The big culturopathic US healthcare companies operating in a similar marketplace in the 1980s and 1990s realised marketing and recruiting were the most important activities for them if they were to succeed in that aggressive marketplace. If you did not get heads that paid well on beds, you could not make any money. Once you had the beds filled, then you could maximise your income by concentrating on offering services.  Without an effective customer, competition was about persuading people into hospital and then making as much money from them as possible. It did not matter that most of them did not need to be there.  What was so surprising is that hardly anyone who was part of the service thought that this was inappropriate. 

My concern is not about collecting information from residents, but the extent to which the context within which it is being done becomes more about getting heads on beds than about accurate information. I am concerned at the extent to which this distorts the whole process so that it is rorted and does not work. I worry that in its current form it takes resources and focus away from care.  The difficulty is when people don't see anything wrong in what they are doing.

I am interested in how the proposed hub can create educated reviewers, counter the distortion caused by the focus on profits, simplify the process, ensure the focus returns to care rather than strategies to recruit at all cost, and can make it work effectively for all parties.

Getting information from staff and residents: Providers should of course be doing anonymous surveys of their residents and staff with confidential forms or interviews done by somebody independent.  They need feedback and accurate information on issues so that they can be addressed.  I suspect that this has not been happening in most facilities.  The only surveys we hear about are positive ones used in advertising.   The number of staff who are fired after speaking out suggests that management are not receptive to criticism.

Accurate results: If the results from surveys are to be used for marketing, then there is certainly pressure on them to improve their services and do well.  But there will also be pressure to ask the sort of questions that will give the answers they want, to select people who will respond positively and to employ surveyers who think like them and will give them what they consider are reasonable results. 

Surveys by questionnaire or structured interview can elicit more information than other sorts of surveys and can explore individual care situations in more depth.  The extent to which interviews do that and report it, is not always clear.

If the surveys are to be valid, then the questions asked should be those that knowlegeable residents, families and communities want asked and not necessarily those that the providers want to ask. Unsolicited comments are valuable. If the community is to help in generating questions then they should be sufficiently informed to know what to ask. They should not be swayed by advertisements from providers or government. All of the seniors groups and the community should have input into the questions asked and not only one.

For example, it is important that nursing and palliative care receive attention and that families who have been through this are questioned. The proposed hub would be in a good position to educate the community and to ensure that a broad selection of people participated.  They could oversee and manage surveys like this.

Quite apart from the actual collection of data there is the possibility that a false impression will be created, or that care will be compromised for some. For example:

• The distortion of services: Some providers might be tempted to target their resources to those who can respond positively or have interested relatives who visit and will participate in surveys. Those without families, bedridden and with dementia who usually need more care, might not get as much attention as those the facilities need to please. Perhaps I am too pessimistic about the extent to which strong incentives can override empathy and ethical commitment, but I never cease to be amazed at what can be done by some enthusiastic entrepreneurs when what they do works for them.
• Impression management: Impressive facilities designed to appeal to shareholders will also appeal to friends and family. 'Impression management' can have a big impact - and the responses may not reflect deficiencies in staffing and the actual care given in the privacy of bedrooms. No one wants to go into an impressive facility with glowing reviews and then find six to twelve months later when care is needed, that there are insufficient staff to provide it.
• Cherry picking: Picking healthy residents who will enjoy the amenities offered, will reduce the need for nurses and the sort of care that generates complaints.
• Standards: It is important to understand that while feedback from family and visitors is very useful, it is not an accurate measure of standards of care and both need to be evaluated and considered together.

Structure of the this web pages: In the next section of this web page I am going to look at who the providers of feed back services are and how they operate.  After that I will look more widely at the feedback sector to see where it has gone very wrong and then at the extension of this to the health and aged care sector to look at the development of similar problems there.  I will end by looking at how the proposed hub might prevent these problems from developing.

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The NRMA/COTA surveys

COTA, a member of NACA has teamed up and created a commercial enterprise with the motorists support group NRMA in NSW. In this project, good providers will spend a large amount of money to be assessed by a survey organised via Gallup. This will then be published by NRMA. The "OWL" rating developed from this survey can be displayed on the provider's nursing homes and be used to advertise. By paying more money, providers can advertise and display photos on the NRMA web site.

The NRMA: The NRMA (National Roads and Motorists Association) in NSW has a long and sometimes turbulent history. It is now two closely related organisations, the motoring service and the financial services insurance business. The financial services sector demutualised in 2000 and is now for-profit with shareholders, but both work closely together and have become much more commercial in their focus and operation.

Living Well program: NRMA is developing a "Living Well" service for seniors in cooperation with COTA. The site indicates that the "Living Well Navigator aims to be Australia's leading consumer-driven platform for information on retirement living and aged care - including an unrivalled database of services and facilities". It is going to have "OWL Ratings and Listings". There is information indicating that it is going to work with and be complementary to the governments "My Aged Care" website service. The details are in the terms and conditions and on the OWL ratings and listings documentation.  Note that this is being organised by the NRMA for the providers to acquire OWL ratings and they are paying for the privilege.  COTA is a seniors organisation that works closely with providers on NACA but "consumer driven" does not seem to describe what is being done. 

The documents set out the right of the provider to use the NRMA site, to make comments and respond to critical comments from residents and families. The fee is $2,900 or $3,900 depending on the size of the facility. An additional $550 creates an enhanced listing which will allow advertising and photos by the provider. This allows the provider to upload up to ten photographs or videos, add content, link to a website and have the listing prioritised in searches on the NRMA web site. So you get more exposure to potential customers if you pay more. Like the NRMA rating systems for hotels, this is an advertising tool with a requirement that you pass an approval test first.

I was interested in what the relationship of 'consumer engagement' to  'consumer's opinion' of the services was. The explanation offered was:

Is 'engagement' the same as 'opinion' - and why the different term? What is the survey actually intended to solicit? Are they going to only ask about things that appeal and will get a positive rating by those still healthy, or will it include issues about quality of nursing care for those who are not healthy or who need palliative care?

In responding to objections made to the ACCC, NRMA lawyers indicated that “Customer Engagement measures what it is an operator does that constantly delights customers”. OWL ratings “provided an opportunity for operators to differentiate their services on what is most valued by customers”. They stressed this was not an accreditation system and that it “does not purport to rate the quality of health and care provided by a Provider”.

So COTA and the NRMA are advising seniors making major life changing decisions, when entering retirement villages, nursing homes and seeking home care, to select a provider that “delights customers”. It looks as if what happens to them when they are too frail and sick to be delighted is not important!  On its web site NRMA says that "Owl Rating is a prestigious recognition of the quality of a service, similar to receiving a 'Chef Hat' in a great restaurant"  Does this accurately reflect quality of service?

The Questions: The questions asked are on the OWL rating and listings document. They are not very specific about actual situations. Most seem to have more relevance to retirement villages than nursing homes. But many retirement villages are closely linked to nursing homes.

Owl ratings:  While aged care facilities are included, the information suggests that retirement villages are the prime target and their ability to advertise themselves is the driving force in this.

Examining the website

On examining the website (April 2016) I found that it took a very positive approach to ageing and to quality of life with plenty of happy images. There was a large amount of useful information about how to approach retirement, home care and residential care. Retirement can certainly be one of the most fulfilling parts of ones life and we all want to make the best of it. There are advertisements promoting holidays and trips.

We have the capacity to make the best of almost whatever situation we find ourselves in. But we also need to be realistic about what confronts us and many will come to this site towards the end of their retirement at a time when, whatever we do to delay it, most of us are declining physically and mentally. If we are to make the best use of our time we need to confront the situation and plan our lives. How do we balance the positives and the negatives when giving advice? Happy unrealistic images that are unattainable will depress rather than help.

There was a check list of what to think about and look for in each sector. But it is interesting that despite all the debate and information available about staff numbers, skills and rostering, the residential facility advice in the check list about staffing avoided these issues and was very general.

In addition to information supplied by providers, there was a panel where users could write a short review of the service and rate it on a 5 dot point scale.  To sign up to leave a review you had to register and get a password.

Available information

At present, the site lists the nursing homes in Australia, provides contact information and other information that is readily available elsewhere.  It has a long way to go if it is going to be useful in asssessing and rating nursing homes.

• Of the 1,855 Independent Living (retirement) services listed, only 27 had applied for and been awarded OWL ratings. Most were in NSW with a few in Victoria. Of the 1,855 facilities, only one user had made a comment and rated a facility.
• Of the 2,800 residential care facilities there were no OWL ratings available and no user had rated a facility or made a comment.
• Of the 5,228 Home Care services listed there were no OWL ratings and no user ratings.

Problems

A major problem with this endeavour for the community is that it is voluntary and if the provider does not perform well, the NRMA will not post it. It can try again, but bad homes are not going to be allowed on the site as they don't get any OWLs.

They are treating it like a hotel, a Bed and Breakfast, a restuarant or a holiday park and the questions are along those lines. I am not persuaded that this is the best way to rate something like aged care.  To my mind it reveals the commercial mindset of those organising aged care.  In the face of evidence and reason, aged care must be squeezed into their model - one transported from the very different holiday industry - "market-think" at work creating illusions.

A prospective resident needs information about the facility including objective measures of care, particularly the hours of nursing care and the skill levels provided per resident. They might not realise the importance of this if all they are offered is a survey of positive opinions by those still well enough to provide them.

A single rating of the type done for hotel accommodation and caravan parks is not suitable for the complexity of care and the many different requirements of residents in nursing homes. A single rating will be weighted by what is asked and major deficiencies may not be revealed because of the way it is weighted.

A blunt instrument: Compressing all of the findings into a single rating will not tell the family looking for a home how the provider performed in what they require. Hopefully there will be an analysis of the findings for each facility placed on the NRMA web site with more detail on these issues.

To be useful, the performance in different categories and even the entire set of responses should be available. I do not know what is planned by COTA and NRMA in this regard.

Review of the OWLs by the ACCC

After I had written this section my attention was drawn to material on the Australian Competition and Consumer Commission (ACCC) web site.  When I saw the submissions I was reassured to see that others felt as I did.

Application for certification: The ACCC assessed an application to have the OWL ratings certified as a trade mark. Certification implied and gave users an assurance that the trade mark did reflect a superior service and was beneficial so giving greater credibility and a business advantage.

NRMA claimed that it had consulted with and been advised by aged care bodies, providers, retirement organisations and several other bodies, but none made a submission to the ACCC to indicate support when the ACCC invited and even wrote to organisations inviting them to comment on the application.

Three organisations did respond. One was confidential. The other two were from bodies representing retirement residents in Western Australia and Victoria. Both were highly critical, thought the idea potentially harmful and did not support the application.

Issues raised

The scheme sounded good but was 'fraught with problems'. These were major decisions often involving peoples life savings. Dissatisfied residents suffer economic loss if they decide to leave. The surveys and questions asked were simplistic and loaded to ensure a positive outcome. The Victorian submission suggested that the questions should instead be designed by "the National Ageing Research Institute (NARI) who would be able to supply the questions in the proper format for a true result".

There were many more variables to be considered. The same approach was not suited to residential care or home care. There had no value for residents and large providers would be coerced into the scheme by market pressures. There was a risk that the scheme would be confused with accreditation ratings and customers might not recognise its limitations.

Concern was expressed about the impact of 'intimidation and bullying in these villages (which) occurs too often?' on the surveys. It was felt that ultimately, it was the residents who would pay the fee as operators would pass the costs on. The selection of residents to participate by the management or owners was questioned and the influence of large numbers suffering from dementia was raised. The Victorian submission indicated that if a “true accreditation” was to be undertaken, then it should be mandatory for ALL villages and should be undertaken by the State or Federal Government”.

Response to the issues

In their response, the company lawyers claimed that the scheme met all of the objections. The Customer Engagement questions were derived from 'B2C businesses across a wide range of industry sectors' as well as Gallups experience in health and aged care in the US - confirming that they were ported to the sector from elsewhere and not local.

Certification approved on 20th April 2015

The ACCC accepted the lawyers response and concluded that the scheme was 'unlikely to be misleading or deceptive to customers' - was 'not to the detriment of the public' - does indicate 'to consumers that a product or service meets a particular standard' - is likely to provide a public benefit and that any public detriment is likely to be limited. The application was approved. The ACCC does not indicate which experts, if any it consulted.

An overview, additional information about the OWL ratings  and links to the material referred to here can be found on the ACCC website.

Links to pertinent material refered to is below

• Submission RRVV (Residents of Retirement Villages Victoria Inc) 31 Aug 2014
• Submission WARVRA (Western Australian Retirement Villages Residents Association Inc) 22 Aug 1014
• Response to ACCC Gilbert Tobin Lawyers for NRMA 24 Oct 2014
• ACCC Assessment of National Roads and Motorists Association CTM application 1568411 

Is this to counter adverse publicity?

There is obvious merit in encouraging providers to be involved in assessing  their services, but this seems a remarkably skewed and selective sort of assessment.  I find it difficult not to see this as an attempt on the part of 'the family' to counter what they see as unfounded criticism, fuelled by a biased press based on 'isolated and infrequent failures'. They want to showcase all the good things that happen and not have any bad homes that will generate bad publicity up there.  I would much rather that senior's groups other than COTA, with its close links to government and to providers through NACA were doing assessments of facilities.

I worry that they may be trying to create an impressive image that obscures what is really happening in the sector - and so frustrate the changes that are needed to sort the system out and make it work for the community. With the sort of system we have today, really frail and sick people badly need to know who to avoid - and without an assessment of what happens when you reach the end of your life it can be deceptive and in my view harmful.

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MyAgedCare website to emulate Trip Adviser

As indicated elsewhere, the government's MyAgedCare website is an example of top/down controlling managerialism. It is an inappropriate thought bubble and there have been numerous problems. It has been heavily criticised.

Instead of sorting out the mess, the government is focusing on its market agenda and on selling its illusions. The government has decided that the holiday image of aged care is a good idea so it is joining the show. The market has worked in the holiday market so it is adopting it.  It is planning to offer a service modeled on Trip Adviser on its MyAgedCare website.  Trip adviser is the go to website for holiday makers planning their holidays.  Planning how you spend the rest of your days and how you will die is a little different.

The idea was first floated by the assistant minister for social affairs Mitch Fifield under the Abbott government in March 2015. At that time he was responsible for aged care. His comments below to a meeting of COTA illustrate the thinking driving this web site and the illusions that underpin the government's policies.

Note the comments about transparency and an informed customer, neither of which can be applied to the MyAgedCare website or the often confused customers in aged care. Then there is the argument that this newly informed customer (by the providers whose information is reproduced on the website) knows what really matters when she chooses an aged care service - illusion on top of illusion - putting what they would like us to think into our minds.

While the Turnbull government has a new face and has abandoned some of the policies that so angered the electorate, they have only changed the policies that the electorate forced them to abandon. Aged care was not one of those. In November 2015, the new Health Minister says almost exactly the same things playing on the communities lack of information about the real issues in aged care.

The comments made on this article reflect the level of understanding that the responders have. Two typical sets of comments reflect the different way people understood this.  It also reflects the attitude of many in the industry to the widespread unhappiness.  They just don't get it that there are very real issues out there about the service that many of them provide.

One of the most insightful critics of our aged care system is Professor of Sociology Michael Fine, who has both personal experience and an academic interest. His criticism of the Trip Advisor idea is well worth reading in full.

Concern: Let me make it clear that it is not the appropriate use of a market nor the important role that technology and the internet can play in supporting community services including aged care. It is the way that they are being used to confine, control and limit our human potential and prevent it from developing solutions and innovating outside narrow marketplace constraints.

It is the strange and obsessive belief and the naivety with which complex multifaceted issues are squeezed into preconceived ideas where they don't fit and can only create problems that is so concerning. It is that solutions are created first based on a belief system. They are then imposed on situations where they cannot possibly work and where incredibly, the politicians who voted for this often haven't the faintest idea what they are voting for. 

The following from the not-for-profit Aged Care Services group in NSW says it all:

In a sensible world you start by carefully studying each situation, collecting as much information as possible, evaluating it and looking at its implications and the possible explanations, doing further studies and testing out explanations. During this process you look at the various options and then try out those that hold up when looked at from multiple different points of view. Situations that may have worked elswhere need to be set against the particular situation to see what their impact will be.  Applying formula based on an ideology developed elsewhere is crazy but when you believe in the ideas it happens.

As a model of participatory democracy the proposed hub is intended to create a pool of intelligent and knowledgeable people with a broad range of experience and insight close enough to aged care to know what is happening. It will be well placed to move what we have towards what we would like in a more sensible way.

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Advisers to the industry participate

The government's focus on a competitive market has spurned a whole new industry of consultants and advisors offering services to the industry to help them compete, grow and consolidate, and some of them are trying to serve the customer as well.

A group of businesses linked by their directors seems to be exploiting the opportunities provided by both of these markets.

Ansell Strategic Services offers "strategies for the leaders of aged care organisations". They include business diagnostics, strategic planning, turn around planning, change management, capital developments, mergers and acquisitions, among their services. This is one of a number of commercial and legal consultancy firms offering services to the aged care providers.

Aged Care Ratings: Cam Ansell from Ansell Strategic Services, Ben Hanneman from Aged Care Online, and Dana Sawyer from Millenium Aged Care Placement Consultants are the founders of Aged Care Ratings. Aged Care Ratings offers an interesting star rating service for providers wanting to inform consumers of what they offer.  Aged Care Ratings opened in Melbourne in April 2014.

As far as I could see from the Aged Care Ratings website, all of the information used for the independent ratings were supplied by the providers and they awarded the stars to themselves. This service was free. For an additional fee of $1,900, Aged Care Ratings would visit the facility to "verify" the claims. After that, the ratings would become "certified" ones and could be advertised as independently verified.

It is important to note that standards of care and quality of life are not among the items rated. 

As Aged Care Ratings' business depends on providers wanting to be certified, there seems to be a conflict of interest. If they rejected too many providers assessments then providers might not bother to spend the extra $1900.

Aged Care Online: Working closely with the ratings service Aged Care Online provides an opportunity for providers to publish a facility profile as well as "pictures, descriptions, virtual tours and video tours". They also list their bed vacancies so that prospective residents can see what accommodation is available and the costs. Aged Care Online provides for "user reviews where consumers can comment and share their experiences with their nominated aged care facility".   Many facilities provide information but a large number have not and here a contact email form is provided.

Consumer feedback is available as a short review on the site.  Many facilities had supplied information and costs, but there were not many with reviews by consumers.   Only a few had consumer reviews (1 to 3 reviews mostly).  Of the several facilities I looked at, all of the comments were positive.  I did not see any criticisms. 

Homes that have a "verified" star rating from Aged Care Ratings have this displayed as a "certified rating".  It is not clear to me how the self rating stars were used.   I noticed one or two reviews had star ratings next to the reviews, but it was not clear to me if these were the providers assessment, or whether this was an assessment by the reviewer.

Millenium Aged Care Placement Consultants: The third business is part of another large industry that has sprung up in response to the complexity of the system for the communiity - the 'Placement Industry'. These are organisations that act as consultants who advise and assist potential residents and their families helping them to find the right place for the disempowered seniors. Aged Care Guide has a list of 36 Australian placement organisations on its web site.

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DPS Publishing

DPS Publishing is an organisation that works with the industry and publishes guides for prospective consumers of aged care. These are handed out by providers as a source of information. Not surprisingly, it toes the government and provider line. They operate the "Aged Care Guide website" They interviewed the minister and came up with an article praising the minister and supporting her plans. They are also wanting to start a user review web service. It's as if the 'family' are trying to fragment and break up the whole feedback process so that it cannot work effectively.

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Reservations

I have not attempted to explore all of these multiple services in depth.  I suspect that most of these groups are genuinely motivated and are, or believe they are, serving the consumers. But this is a slippery slope and there are no effective customers to discourage the sliders and push them back up again. In a competitive market, those who are not prepared to slide a bit can cease to be competitive and are likely to be acquired by those who are.

The people running this are also acting as consultants for the industry so are working closely with them. What it also reveals is the increasingly large overheads that have resulted in the costs of nursing home as well as home care cutting more and more deeply into the funds provided for care, with little left for staffing. Seniors are shortchanged.  Having a much simpler system that did not have so many overheads would do much more to empower the residents and their families.  This is what the proposed hub is intended to do.

There are currently far too few reviews for these to be of any value to prospective residents and this is probably due to the fact that this marketplace is saturated.   The sites do give very useful information about what services each facility provides and the costs.  Clearly residents will have to go and look for themselves to be sure that the information supplied by the providers is accurate.

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The participants

The multitude of industry and government web sites might just be an attempt to drown out the more open and uncontrolled independent computer feedback sites that are springing up and that they can't control. Some of these are being developed by dedicated people who have been harmed or who have seen the real face of aged care. One has a strong corporate focus, another a multinational not-for-profit and recently a global US market listed web feedback service. Participation and misuse is potentially less controlled and those who are unhappy will tend to go to these sites and this could create bad publicity for the industry.

These sites may not give the depth of information obtainable by a Gallup survey. On these these sites, areas of particular interest are rated separately and there are comments which indicate what the individual problems are. So you may get 5 stars, but you can also see what each one was awarded for and where the problems were.

It concerns me that there is at least one group who see the feedback and provider response web developments as a commercial opportunity with global potential. This shifts the focus of the feedback program to growth and profitability.  As I have argued, this has inherent risks because of the strong incentives introduced.  It would be sad indeed if this commercial operator put the community endeavours out of business. 

The participants

In 2012, "Patient Opinion", a group that has been pioneering the use of online consumer surveys through the UK founded Patient Opinion Australia creating a system for getting consumer feedback on health care in hospitals. Articles can be found here and also here. It is also now doing the same for non-hospital care including aged care. Their Care Opinion website applies the same methodology.

Another website Aged Care Aware offers a very similar service and a Facebook page.

Aged Care Report Card is another endeavour along the same lines and its website is very impressive. 

Aged Care Reviews is an ambitious commercial enterprise that raised money from investors, but not enough to enable it to float on the sharemarket. From a small beginning it is ambitiously targeting a global market. 

The giant market listed US global feedback company Yelp dominates the tablet and phone marketplace. It now operates in Australia and offers to rate aged care facilities as well as everything else.  

These websites solicit critical comment and ratings from the community and then provide feedback to the providers who are given an opportunity to address the issues. They vary in what they offer in the way of advertising for providers.

• Care Opinion is a not-for-profit and a subsidiary of Patient Opinion. It describes the grants and money it has received.
• Aged Care Report Card indicates that it is a "privately funded independent organisation" but does not disclose the source of its independent funding.
• Aged Care Aware does not indicate where its funding comes from.
• Aged Care Reviews is targeting the industry, is strongly commercial, has raised large sums from investors and plans to go global. 
• Yelp is a global corporate entity and aged care is only one of its activities.  It has been embroiled in controversy.

All claim to be independent of providers and government. All provide feedback and response opportunities for providers. They aim to help providers, as well as the families making difficult choices. Although the source of funding is not always disclosed, some seem to depend on providers who register with them and in return are offered increased opportunities to get feedback, respond to criticisms and to market a positive image. Usually a fee is involved.

Although it is not explicitly stated, it is clear that the accumulation of responses is going to depend on providers telling residents, families and friends about the site and directing them to give feedback. I see this as commendable and a useful tool for motivated providers seeking to improve the care offered, and give greater satisfaction to their customers.

A good idea: Although useful, I do have reservations about their utility as an information resource for prospective residents and their potential to be gamed by providers that are not as motivated by a mission of care. I am supportive of the general concept and see considerable merit. But my interest is in where, how and why things go wrong and the utility of what is offered for "consumers". My experience is that when there are strong competitive commercial pressures there is a strong likelihood that any weaknesses in the system will be exploited by some. When this gives them a clear financial advantage, competitors will have little choice but to follow if they are to compete and survive.

Viability: The first point to note at the outset is that there are (currently) at least seven separate feedback services. One must ask whether Australia can support this number and get sufficient responses to yield valid information. Most be competing for the patronage of providers. Will the providers enrol and support all of them, will they focus on the one that offers them the best marketing opportunities or will they all boycott these sites and use the NRMA and MyAgedCare website so possibly neutralising criticism?

Market forces: It is a pity that to make these sites work they seem to depend on providers to support them rather than the public. If it were the other way around, I believe they would be much more effective and ultimately more useful for the community. They must present a positive image to the providers and I do not see anything wrong with that as they all genuinely want to help both and they want to improve the service.  Its the leverage that financial dependency gives providers that worries me.

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More information

Care Opinion seems to be the most experienced. It gives the most information about itself, its funding and its efforts to address bias and conflicts of interest. It does not focus exclusively on aged care nursing homes.

Aged Care Report Card gives some useful information about itself. The items selected for rating are good and what people want to know about. The person running it has plenty of experience in the industry and is dedicated. The founder has been careful to dot all the "i"s and cross all the legal "t"s. A great deal of effort has gone into this and the site is impressive. 

Aged Care Report Card has appointed a well selected advisory committee with representatives from a seniors organisation, nursing bodies, publishing, business and technology, but not from providers.  It is sponsored by seniors groups and nursing representative groupd  as well as business groups not involved in aged care.

As a past worker in the industry, she has gone to the nurses union and to various carer and community senior organisations asking them to encourage people to give feedback.  It is encouraging that the Australian Nursing and Midwifery Federation has a link on their website so is supporting her and is likely to encourage their members to ask people to provide feedback.  Carer organisations may do likelwise.

Aged Care Aware is written by someone who has had difficulties in dealing with the system. It seeks to promote dialogue and improvement. It offers providers the opportunity to post pictures and promote themselves to readers. They may not have outside funding and may be more dependent on funding by providers who pay to join. They do not disclose who they are on their website, so we have no means of tracking their credentials or researching their backgrounds. We have to accept what they say at face value.

Aged Care Reviews has a very different approach that needs some scrutiny. Its founder Kenneth Ray is a businessman with a law qualification from Melbourne University. He saw the opportunity when helping a relative. He sees this as a business opportunity and is very ambitious. He has assembled a team of directors  from the business world and the industry.

The business has raised $600,000 from investors.  The company hopes to increase that to $1.4 million.  It is planning to go global.  It is developing a feedback application for mobile devices which it will sell.  It is clearly targeting industry and offers them advertising, but it also targets seniors directly through social media. When viewing the feedback on facilities owned by some groups, your reading is interrupted by popup windows inviting you to view and inspect the facilities.  I found this irritating.

The company has secured a Smart 100 rating for 2015 from Ant Hill a publication that promotes innovative startups.  It is worth looking at what they are saying. As far as I could tell, the company is being promoted by startup publications but not yet by market analysts and the major business magazines.

I am not a businessman, but wonder about the business model and how much the business will have to compromise and give providers what they want if they try to meet these very ambitious goals.

For a company seeking to make money from providers, they got off to a bad start by commenting on providers in a media release. The company's ambitions depend on their support. 

The buyer beware approach may be good advice, but the language used precipitated a furious response from ACSA on its website and in an article published on Australian Ageing Agenda:

More than a year later and Kelly and Ray are still disagreeing. The Gold Coast Bulletin published an article suggesting that the Aged Care Reviews website revealed that the Gold Coast was receiving the worst reviews in Queensland. ACSA seems to be particularly sensitive to criticism and its CEO took a broad swipe at the objectivity of the whole idea behind the review web sites. 

Kelly is of course correct.  Individual assessments are often subjective, but aged care is now a marketplace and it is the combined subjective impressions of the community from whom the customers are drawn that makes the market work.  It's all that is available to them. 

A guided tour by someone trained to sell their services creates a false impression and can be less reliable. Its very sad that potential residents don't have objective data (eg. staffing and frequency of failures in care) but that is the way it is in this marketplace and that is what the industry worked with the government to create.

If the industry wants this to be different and to be based on accurate information, then they need to start talking to the community, but before they do that they need to support the proposed aged care hub so that they have knowledgeable people to deal with and have credible data that the community is satisfied is accurate to talk about.

Yelp: Yelp does not have much of a footprint in the Australian aged care marketplace but the intense debate around its activities in the USA and the multitude of lawsuits are a good illustration of potential problems in this business as it becomes ever more commercial. Yelp has become a massive success story. Google and Yahoo have both attempted to buy it.  It has been dogged with multiple allegations that have alleged the system has been rorted.  The courts so far have thrown out all of the allegations but with so much smoke and similar allegations made elsewhere we are left wondering.  I examine all this in the section on rorting later.

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Making these groups consumer driven

Interestingly, once I got past the annoying popups inviting me to visit, I saw some very critical comments about one of the big market listed providers  on the Aged Care Reviews site.  This was encouraging in light of the Aged Care Reviews business model and ambitious targets.

Conclusion: A great deal of effort and money has gone into creating these independent web pages and setting up the services.  I ask myself how well they will stand up when competitive pressures threaten their viability? How far will they go to appease providers in order to remain viable and meet their objectives? Will the providers see strong criticism as biased and ill informed and object? If one site provides advertising and limits the publication of critical comment, will the others be forced to follow?

The incentives in the system are not positive for consumer's interests and the utility for reliably informing families may depend on the mission and integrity of those running the service.  In a strongly competitive markeplace in vulnerable sectors there is little room for mission and integrity.

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Examining the web sites April 2016

This page was written months ago but publication was delayed. I went back to look at what was happening.

Care Opinion and Patient Opinion: These websites publish contributors accounts of their experiences. If there is a problem, they contact the facility and request a response that is published. I searched for Residential Aged Care and got a list of hospital and aged care items most of them 2 years or more old. I then went to the sister site Patient Opinion and got an identical list. The only difference was the heading. This does not look like a lot of activity or a serious attempt to enter the sector.

Yelp: Yelp targets the tablet and smart phone marketplace. It rates restaurants and other businesses. It entered Australia in 2011 and operates out of the major cities. A Search in the category “Care Homes & Nursing Homes” showed that 44 were listed in Brisbane, 193 in Sydney, 38 in Melbourne, 102 in Adelaide and only 13 in Perth. Of the 390 not one had been rated.

Aged Care Aware: I did a search of a little over 100 facilities around the major cities. In Melbourne, two of these had been reviewed by one person and one by two people. In Sydney and Brisbane, none had been reviewed. In Adelaide, two had been reviewed by one person and in Perth one had been reviewed by two people. Out of over 500 facilities, only 6 (1.2%) had been reviewed. The reviews were mostly either excellent with a rating of 5 or else very critical with a rating of 1.

Aged Care Report Card: Aged Care Report Card has appointed a well selected advisory committee with representatives from a seniors organisation, nursing bodies, publishing, business and technology but not from providers. Because I could search for all of the facilities in each state it was possible to roughly assess the extent of its coverage and the number of reviewers. I did not look at the Northern Territory.

Reviews per facility reviewed

Only 8% of those reviewed had more than 3 reviewers

Aged Care Report Card had reviews of between 13% and 19% of homes in Victoria, Queensland and South Australia but in the other states it was roughly 5% and the average was 11.8%. Only 3 facilities had 10 or more reviewers and in 236 (68%) there was only 1 reviewer.

Aged Care Reviews: I did roughly the same search that I did on the Aged Care Aware site and obtained far fewer results. I obtained about 100 facilities for the major cities using Aged Care Aware but obtained a little over half that with Aged Care Reviews. As a result, I do not think that the incidence of reviews is comparable with the other web sites. With Aged Care Reviews, I added Toowoomba, Bundaberg, Rockhampton and Cairns to the 35 I got for Brisbane to increase the numbers to 84. I looked at Melbourne (58), Adelaide (29), Perth (62) and North Sydney (22) to give a total of 255. Of these 98 (42%) had reviews and except for Sydney where there were fewer this was representative.  As I indicated earlier, I suspect these figures are skewed by the different sampling.

Reviews per facility reviewed

Only 5% of those reviewed had more than 3 reviewers

In summary

It is not possible to get a true incidence of the facilities that have been reviewed by a reviewer probably because what the different groups have classed as a nursing home or residential care facility differs. It is certainly not high in any of them. Only two groups seem to be serious players in this market - Aged Care Report Card and Aged Care Reviews. The reviews of both provide a range from good to bad with comment indicating what the problems are.

Despite all of the hype, there does not seem to be a lot of enthusiasm on the part of residents, families, visitors or providers to carry out reviews or to encourage people to do so. Were providers encouraging residents and families to review you would expect in the region of 10 or more reviews of each facility over time. Only 4 had this many. Very few facilities have sufficient reviewers with roughly two thirds only having 1 review and only 5 to 8% more than 3. This makes it an unreliable resource, although the responses can point you to potential problems to check on.

If the proposed Community Aged Care hubs were in place then they would be well placed to enlist sufficient people with experience and knowledge to make this viable and reliable.

Both Aged Care Report Card and Aged Care Reviews require users to register and give details before making a review.  They consequently have some control over this in preventing inappropriate use.   Both seem to attract many more critical comments than the groups that are more closely associated with government and the industry. 

Government and the industry have avoided any sort of transparency over the years and are very defensive when issues are raised.  One wonders therefore if the recent enthusiasm for trip adviser and other industry feedback sites is influenced by this - an attempt to give a less biased perspective.

Aged Care Report Card has an advisory board which is far more focused on seniors. It is sponsored by nursing, seniors and business groups but not by providers. It recruits through community and professional organisations. My impression was that there were more health and aged care professionals responding so there may have been a greater level of expertise and fewer gut responses. Its web site is the most sophisticated and easiest to use and gives more useful information about each facility.

Aged Care Reviews is a commercial enterprise funded by investors. Its leadership team comprises entrepreneurs and businessmen. One is on the board of Council of the Ageing (COTA) NSW.

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Are consumer's opinions a measure of standards of care?

Aged care is a service to the community and the views of consumers are important. We need to know that they and their families are satisfied with what they are getting, and if not why. The problem for studies of community opinion is sample selection and sample size - also temporality. The questions asked are critically important. A lack of understanding and insight limits their utility. This is something the proposed Community Aged Care Hub would address.

Consumer satisfaction is  particularly important in this sector because it reflects quality of life.  But it is very important to understand that consumer opinion, while it is very important in a market, especially for the providers of services is not a measure of the care given. It can expose problems but it cannot be used to measure and accurately compare the standards of care.

Potential residents and their families should take it into consideration, but it is not quite as important for the resident's welfare as an accurate assessment of the standards of care and the quality of life. The proposed aged care hub would come from the community, would be dealing directly with residents and their families and would be seeking their views in confidence. It would be collecting objective data about care and quality of life, and would have experienced the ambience in the facilities. It would be well placed to help prospective residents and families in balancing the satisfaction and approval revealed by these ratings against the actual care being provided. The local hubs would have first hand knowledge of local facilities and their suitability for the individuals they are dealing with.

Dr Low is saying that perception can be more real for the vulnerable person than the actual standard of the care that is given. The relationships rather than the care provided dominate perceptions. Every surgeon knows that it is those patients whose treatment has gone disastrously wrong who are often their most loyal supporters and this is because of the close relationship that builds up between them during this difficult time for both of them. The empathy and dedication of nurses who struggle to provide care and relate well to families may create a positive impression and hide the understaffing that gave rise to the problem in the first place.

Humanitarian provision of Health and Aged Care are unsuited to a market partly because the motivation driving good care is not profit, not the desires of the person receiving care, nor that person's satisfaction. It is the best interest of that person. Although that person has autonomy, the doctor or other carer's duty is to advise them and if need be guide them towards what is in their best interests - but that is sometimes complex with many ethical parameters to be navigated. No good doctor will give someone treatment simply because they want it, particularly if there are consequences.  Patients are not always satisfied even with a very good outcome. People who get good care can be unhappy.

There is also some scientific evidence. For example studies have found that more personal care results in greater satisfaction but not necessarily with better "quality of care." Control, or the perception of control, as for example in consumer directed care "appears to increase satisfaction with care and community service use but has little effect on clinical outcomes."

So, feedback from residents, family and friends is important and very helpful, particularly in this sector - but it has its limitations and this is particularly so when the person is completing an itemised survey designed by someone else and not putting their own thoughts into words.

The comments above relate mostly to health care and while they are relevant aged care does have some differences. The persons comfort, satisfaction and perceptions of wellbeing are relatively much more important than whether some omission has precipitated an earlier demise. Feedback showing their satisfaction has greater validity.

The danger is that market focused entities will concentrate their efforts on getting the best possible survey and then use that, rather than measures of care in their advertising. This is the way the market thinks and customer satisfaction is their primary concern. People looking for a facility may not realise that they need much more than this. Its easy to find surveys that describe stellar performance, but I have not seen many critical ones although they must be there.

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Community opinions about consumer feedback

I quoted some critical comment about below an article about the proposed myagedcare trip adviser web site.  While the negative comments were relevant most seeemed to come from the industry.

Community views in the UK: The UK has been using web reviews for longer than Australia. It is interesting to look at the the mixed views of the community in the UK in response to a new Trip Advisor style web feedback site for childcare and eldercare in the UK. Some comments were positive others had reservations and were cautious. I have included the cautious ones below.

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Problems in collecting the data

Awareness:  To have an impact on competitive providers in the market as well as be useful for prospective residents there must be widespread awareness of their existence and their value in the community. It has to become a normal part of aged care for aged care residents and their families to make the effort to participate.  It must become the place to go to when considering aged care.  In an information dense world this falls off most people's horizon.  A recent study of adults with chronic illnesses in the USA reveals a low level of awareness of available information and only a modest increase over time as information programs were rolled out.

Numbers: Without a large enough sample and a representative selection of people who have knowledge and experience, these studies can be misleading. Facilities and companies change hands, policies change and economic conditions change. Owners, whom research data confirms, have the greatest long-term influence on standards, and local managers, who have a short-term influence, all change. Sufficient samples need to be collected at regular intervals and then charted to show the present and previous positions and keep information accurate.

We have seen references to surveys done by the industry showing great satisfaction, and few, if any, showing dissatisfaction, although there are clearly places where people are unhappy.

As I indicated earlier, bias is built into the social dynamics of a survey that depends on providers for recruitment and it is difficult to see how sufficient numbers can be obtained without their assistance. Critics are always suspect and readily labelled as lacking credibility, biased, trouble makers etc. Few facilities would urge people like this to provide feedback publicly. On the other hand, grateful family might want and be asked to express their gratitude.

Numbers and validity: There are 2,718 nursing homes in Australia, and several I looked for on the sites came up, so it is likely they are all there.

To be useful, each of these multiple sites might need to collect a sufficient number of representative reviews for each home in Australia each year - say a minimum of 20 a year, that is 54,360 per year. Homes that did not have the requisite number of verified consumer responses should not be rated, so that prospective residents would know they needed to look elsewhere for confirmation.

A statistician would be in a better position to advise on the number needed, and the steps to ensure a representative sample of people who had real experience of the facility.  The number of competitors in this marketplace compromises the validity of the findings.   Data collection and markets are poor bedfellows. 

Under the current system, to get the numbers, these sites will need to recruit providers and will depend on them to recruit families and friends of residents to make a review. We need to ask ourselves whether they will be recruiting from those who are complaining, or from those who are impressed.

Impression management: Critics complain that the big corporations make themselves look impressive to potential investors by building unnecessarily impressive facilities, but save money and increase revenue by reducing staff, food and consumables. Will the families and visitors also be more impressed by the quality of the facilities provided by the big corporations, or by the less visually apparent quality of care given to those residents who need it?

On the one hand, an aggrieved family might enlist their large extended family and circle of friends to write negative reviews. On the other, a home that is subject to a number of negative reviews is very likely to respond by recruiting those with a positive view of the home and get them to write a review, so hiding the true situation in the home - particularly if they feel they are being unreasonably targeted.

Gaming the system: If I was a businessman and I had a nursing home in trouble, I might go and write myself a review and ask all my friends to do so. I know this is not what is intended, but the temptation is strong and in its present form, this could be as misleading as the star Quality Indicator system that was misused in this way in the USA.

Gullible readers: Too many seniors will use these impressive sites and see some facilities as highly rated. They will not notice or appreciate the significance of only one or two reviewers.

Identifying complainants: Nursing homes often contain much less than 100 residents and there will be a limited number of reviewers. Even with the best of intentions, it will be difficult to prevent them from being identified if they describe what happened. The nursing home will know who is unhappy. To protect them will mean censoring the comment and often removing the criticisms, so biasing the findings. If on the other hand, residents can be identified and are victimised this will have a profoundly negative impact and very few critical reviews will be written.

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Yelp in the USA

There are pressures in commercial operations and the bigger the pressures in the system and the bigger the stakes the greater the incentives to exploit the system.  The pressures in the USA were for businesses to arrange for false positive reviews and for competitors to make negative reviews.  In addition there were incentives for Yelp itself to manipulate the reviews for its own commercial purposes.  All of these allegations have been made. 

Whether these things happened or not has not been revealed as court cases against Yelp have been dismissed by the courts. Clearly large numbers of people believe that they have.  A Television program "The Billion Dollar Bully" about Yelp is being filmed. 

It goes much more broadly than this because the right of reviewers to provide confidential reviews is being challenged in court and if that happened in aged care in Australia then both families and staff would stop providing negative feedback for fear of victimisation. The utility of feedback would be destroyed as they would almost all be positive.

The right to anonymity in giving feedback is being challenged in a case where a business thinks it has been libelled.  It believes that the people giving adverse reviews were not customers at all.  The court has ordered Yelp to disclose who they are to see if they are customers.  The articles looks at the conflicting rights to privacy and the right not to be defamed which has been given precedence in this case.  The implications are far reaching.

Yelp itself is accused of extortion. It is alleged that it manipulated the reviews promising to remove adverse reviews for cash or reduce the impact and number of adverse reviews for those who advertised on its site.

While Yelp has not been convicted and judges have thrown out most of the cases, it is clear that there are a lot of them and many are not persuaded. A television company has been investigating and a documentary Billion Dollar Bully is being filmed.

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Amazon in the USA and the UK

Amazon is experiencing great difficulty with a large number of clandestine businesses that it is claims are selling false reviews to businesses seeking to exploit the vulnerability of the system. The extracts below tell some of the story.

The same article reports that a similar trade in false reviews has developed in the UK.

There have also been examples where some “authors were posting positive reviews of their own work, and negative writeups of rivals, under pseudonyms on the Amazon website”. Amazons attempts to address this in 2012 resulted in some unhappiness.

Amazon removes book reviews by fellow authors - The Guardian, 6 Nov 2012

In the UK some journalists at the Sunday Times wrote a fake book about Bonsai over a weekend and then paid fake scammers £56 (£3 per review) to write fake reviews on Amazon that pushed the book to the top of the Gardening bestsellers category. The scammers used stolen identities from teenage girls taken from facebook.

How to fake a bestseller - The Sunday Times, 11 Oct 2015

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Rorting in Australia

It seems that this practice is already widespread in Australia. The full article quoted below gives several examples.

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Hospitals and Aged Care in the UK

Hospitals

The National Health System (NHS) in the UK has actively pursued an open response approach to getting consumer feedback. The large numbers involved means that, if it can work, it should work there. But there have been distortions due to abuse.

Without a large number of reviewers, and a means of validating them properly, major biases like this are likely, given the competitive nature of this market and the emotional pressures generated there. People's lives and wellbeing are at stake.

Aged Care in the UK

The critical Competition and Markets Authority (CMA) report referred to in the article about Amazon above gave rise to some critical comments from Your Care Home and Care Industry News.  For example Care Opinion’s web site in the UK says “Care Opinion is safe, confidential and independent of services and authorities”. The article below suggests that they allowed care homes to block the publication of comments they did not like. In fairness this was recorded on the site.

Care Opinion in Australia is modelled on its UK counterpart and it may well have adopted the same strategies given Australia’s even more unpredictable and impenetrable defamation laws.

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Aged Care in Australia

The sector is still quite young in Australia and there are as yet no exposures of fraudulent reviews, but then there are so few reviews on each nursing home in any one of the many web sites, that it would be difficult to do so.

As indicated earlier ACSA’s CEO has been critical of web site feeldback. FPCompanyG a market listed corporate provider clearly feels that many of the reviews are inaccurate and that some might come fom competitors. It is critical of the process on its web site.

I note that FPCompanyG do participate and supply details to Aged Care Online which has online consumer reviews. There were no reviews of any of its nursing homes that I saw.   Presumably they will ignore them if they are made and they will not respond to negative reviews if they appear.

Now critics of FPCompanyG might wonder if they have had negative reviews and are in denial. Another way to check on a company is to look at the feedback given by staff. They often comment on the culture in an organisation The feedback sites Job Adviser and Glassdoor run web feedback sites for employees which help prospective staff make decisions. Remember that they will suffer from the same problems as all of the other open web feedback sites.

Pressure from providers: It is inevitable that providers will be upset and angry about negative comments. I have mentioned the hold that providers will have over reviewers when they are dependent financially. But providers can also threaten and possibly sue. One of those review websites indicated in a Twitter post on 18 Feb 2016, that an aged care operator was threatening them in order to take down a critical review. They had refused and indicated they would fight back. Others less familiar with defamation laws, or in a more precarious financial position, might be tempted to buckle and take down critical comment. If there are law suits, this will have a chilling effect on the publication of criticisms.

Related: Streisand effect (Wikipedia)

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The issues

Mark Sadler from Your Care Home in the UK says many of the things that I have said on this web site and I am taking the liberty of copying most of his comments below.

Note the comment about marketing spin above. There is a UK PR company targeting this market. The web review site Carehome.co.uk allows nursing homes to advertise on their site. One PR business Spring Up is offering to write the advertisements for them. Read the whole of the article at the link below this quote and ask yourself if what they are offering is any more dishonest in intent than writing glowing false reviews! 

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In support of feedback sites

Because I have looked at potential problems, does not mean that these things have or will happen. Every system has some weaknesses and some problems develop. It needs to be structured to prevent and minimise them.  What we have encourages them!

Independent  organisations will hopefully have looked at these issues and taken steps to counter them or to watch out for them so that they can step in. In general it is a good idea and one that should be supported if the problems can be addressed.  My reason for a critical examination of potential problems is in order to look at how the hub I am proposing might contribute.

Another article on Your Home Care in the UK sets some goals and makes many of the criticisms I have made here.  It claims to have a software product that resolves them.  It doesn't really explain how that works.

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How the hub could solve the problems

Consumer and community opinion is critically important information and very valuable if it is accurately collected. But it is only one factor to be considered. One of the proposed hub's prime objectives would be to keep track of the local community's expectations and satisfaction in order to support them and guide them to the sort of care that they need and want. But at the same time it will guide and help the providers to meet their expectations - mediating between what people want and what is possible or wise.

The hub in a nutshell

If the proposed hub were introduced it would be well placed to supervise and organise studies of resident, family and friends opinions in a way that gave potential consumers and families what they needed to know. The individualised support and advice they give would be informed by their own direct knowledge of the facilities and be integrated with actual measures of the standards of care, the quality of life and the extent to which residents felt they were in control of their own lives. This would enable the elderly and their families to take control of their own destinies within the limits of their capacity. It would give the providers the information they need and would work with them to find solutions. It would also inform policy. The good facilities would get all the support they wanted from the hub and the genuine reputation that they deserved. Those that performed poorly would be put out of business. That is how the market works. If we have to have a market that trades on our misfortune, then that is how it should work.

Making the websites consumer driven

The analysis I make probably applies to all of the web sites in this section and I have no reason to doubt any of their commitment and objectives. With the changes I am suggesting, it is the websites that the consumers and their communities decide to support that are more likely to prosper.  The local providers would be under some pressure to follow the local consumers in working with that site and to deal with the issues that they raise.

Flaws: The two big flaws in many of the current industry models in the feedback industry lie in the open selection of reviewers which makes it vulnerable and the strong pressures to get beds filled with wealthy people at all costs.  The hub would take control of the recruitment of reviewers and would counter the pressure to fill beds by making what happens to those in them when they are filled far more important.  The community would take control and decide which sites they would work with as well as how many sites were needed to make this work and which ones met their needs - and clearly the needs of the nursing homes they worked with.

Protecting ethical providers of care: The success of any market in serving the customer and community depends on an effective customer. Those providers seeking to serve their customer well are also protected from unfair competition and rorting when consumer interests are integral to the whole system. By recruiting feedback through community organisations, and so making the community's support the critical determinant of success, the potential problems created by incentives that place an emphasis on filling beds above the service provided would be circumvented and the risks of rorting could be eliminated.

I feel that with the cooperation of the proposals I am making more sensible ways of getting consumer's views can be developed.   Most of the difficulties for the sector could be overcome. It would become more consumer driven and not as beholden to support by the providers. There would be more pressure for providers to participate and work with the hub in responding to the feedback given on these sites.

More detail

The numbers problem: The problem of numbers would be resolved because each hub would select the web service that suited its locality or if need be each facility.  It would then guide reviewers to that site.  All the reviews of each nursing home would be in one place.

The hub and web reviews: The hub will be listening and evaluating the community's views often in one on one conversations. These will be given voluntarily and willingly in the residents and family members own words in an ongoing manner.  When combined with an assessment of the actual care given, this will give greater depth and relevance when advising community members. When someone complains the hub would be monitoring remediation to see that issues are addressed and the complainant can see that this has been done.  If the complaint is unreasonable, they are in a position to mediate.   The best way to handle a valid complaints can be by bringing the person responsible for the error and the complainant together in the process of finding a way of limiting the risk of it ever happening again.

But this sort of unstructured data is less useful for analysing the system and comparing customer satisfaction across the country. Information does need to be structured - and this is where a website like this would be an excellent way of documenting opinion, both locally and nationally.  The infrastructure for researchers to explore issues by asking for opinions would be in place.

Control and vetting and preventing rorting: The high risk of rorting in an open system where web sites solicit feedback means that open systems are not acceptable. While I am critical of all of the web sites my personal reason for favouring Aged Care Report Card over the others is that it is independently funded, professional and targets nursing and community organisations in seeking reviewers rather than providers. 

Selection and vetting of participants is is in my view essential if the many problems and particularly rorting is to be prevented. The proposed hub will be in an excellent position to increase community awareness.  It could both direct and motivate those who have knowledge of the facility to do a review, even help the many elderly people who are not computer literate. All feedback could be structured through the hubs. 

By checking the validity of those recruited to complete the form, and then allocating them an access number, they could ensure that as wide and as balanced a selection of people are recruited to respond as possible. While the characteristics of the feed back group could be evaluated no accessible record would link the feedback to any individuals. All those with valid experience of the facility would be encouraged to participate including residents, families and staff - both complainants and those with good experiences.

Researchers would be able to track the nature of the sample, as they would be registered through the hub. They could check to be sure that the system was not being gamed. Fewer reviewers might be necessary to ensure validity. The review might be less easily connected with the person writing it, so reducing the risks of retribution.

Staff: Information supplied anonymously by staff whistleblowers who would not otherwise speak out is particularly valuable. They actually know enough about care and about what is really happening in a facility. The hub would be structured to develop a good supportive relationship with staff. It will receive and will look for confidential feedback from staff.  Hub staff will verify and address issues raised independently. If any staff member's identity is exposed, then they will protect them and ensure they do not suffer as a consequence. 

Changing culture: The extent to which residents and staff are frightened to speak out will soon be apparent to the hub staff as they will be working with staff.  The atmosphere in each facility is one of the important subjective assessments that would be made and which I drew attention to on the page Data handling in aged care.

As facility culture changes in response to the hubs it will become less hierarchical.  The centre for discussion and decisions will move from the board room to the facilities themselves with staff, families and communities working constructively together with local managers.  Hopefully it will no longer be necessary to be a whistleblower and to conceal anyone's identity.

Supporting prospective residents: The hub would be well placed to help prospective residents balance the feedback information with the other data that they will have about the facilities.

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