Aged care: discourse, language and power

Aged care is currently undergoing major changes following the Federal Government’s decision to open the aged care sector up to the market. We believe that these changes will increase many of the pressures, which currently prevail within the sector.  For example, staffing is the largest on-going expenditure faced by aged-care providers and pressures to reduce costs will undoubtedly affect staffing levels. 

There is evidence to suggest that nursing home managers are under pressure to meet their profit targets and reducing staff to do so, often placing vulnerable residents at risk of elder abuse. When staffing is reduced and registered nurses are replaced by lower-skilled staff, care quality suffers. 

A market requires an effective customer to make it work and in almost every sector where customers or employees are vulnerable, they have been ruthlessly exploited and abused.  Where government has contracted services like jobs or vocational training to the market, the services have been rorted and consumers harmed.  Aged care fits into both categories and the many examples of failures in care suggest that this might be happening here.

Marginalising frail residents in aged care: Over the years, frail older people have found themselves cast first as patients needing medical and nursing care in nursing homes where they lived and formed close relationships with those around them.  They were largely cared for by their communities. 

As governments funded and took control of aged care, they became 'residents' not needing much more than basic care, which was provided by poorly trained nurse aids and a diminishing number of nurses.  The community were increasingly marginalised and "hollowed out" as aged care was managed from above. 

Most recently, they have become 'consumers' (or customers) who, in theory but not in reality, are able to pick and choose from a range of (increasingly) commercial providers. "‘Choice", "consumers" and "customers" are the new currency where aged-care services are increasingly exposed to the market economy.  

These changes have everything to do with changes in political and community ideology and little to do with the aged themselves, although they have suffered the consequences. 

Discourse, language and power

The concepts of discourse, power and governmentality have become important in understanding social processes.  Many now use them as a frame of analysis for their research.  These concepts reveal the way that power enables believers to control the data released and discussed, as well as what is acceptable and what is not acceptable within the discourse.  Believers are able to spread their beliefs, exclude anything that might challenge them and so control and constrain citizens by binding them to the discourse (governmentality). 

We can understand how a discourse that is based on illusions has been promoted, defended and protected from what is happening in the real world. Language is important in doing this. The discourse allows believers to control language and replace old words with new ones with different associative meanings.  These create new meanings and hide old ones that challenge belief.   When words are abandoned their meanings and the ideas associated with them disappear from the discourse.

Language examples

Example: "Nursing Homes"

Nursing Homes are part of a language that encapsulates the fact that this is where:

1. Frail elderly people with failing and diseased bodies get the ongoing nursing and medical care to enable them to live worthwhile lives and when life ends, the palliative care they need;  and
2. Frail elderly live their lives in their homes - the place within which they feel secure and are supported to lead those lives and where their community supports them and engages with them.

The words have associative links with frailty, vulnerability, medical care and dependency as well as a place of security (home).  The two are combined into one place.  As people in nursing homes have become frailer and sicker, the practical consequence is that nursing homes have become a hospital within a home - - - the hospital enables them to remain well enough to live well within their home and to maintain their links with family and community.  But this is a major expense. 

Nursing Homes have now become "Residential Aged Care Facilities" (RACFs), words that exclude the nursing care that they need and the home that this is. The emotional content is removed from the words so that it can safely be handled within the impersonal realms of managers, bureaucrats and business. 

Example: "Consumers"

Another word, "patients" - that was associated with vulnerability and responsibility (as well as paternalism) has been changed to the neutral "consumer".   In aged care, the word "residents" has also been changed to the more neutral term"consumer" and more recently morphed into "empowered consumers".

In the discourse, everyone must use those words else reveal themselves as dated, ignorant and out of touch.

We can see how the changed words are closely aligned with self-serving illusions that are promoted through the discourse and, because they appeal to the interests of believers, are readily embraced.

Example: "Choice" and "Control"

In Australia we are being sold the idea of choice without the information, the knowledge and capacity to assess it, or the power needed to be effective and fully in control. To exert choice in any marketplace requires information, the knowledge to assess and use it, as well as the confidence and power to use it.  Without this citizens are at high risk of being exploited. 

The absence of data has made it impossible to make informed choice and has exposed many vulnerable citizens to the risk of exploitation by profit-focused operators. Staffing skills and numbers have fallen to dangerous levels and people are being harmed. Providers won’t even tell us how many staff they have let alone supply any data about the care they provide.

Like all of us, when the elderly and their anxious families face a crisis and a confusing system, they need someone they can trust to turn to, and when there is no one else they will grab the most plausible looking around them. But there is no one there other than the self-interested faces urging them to choose them - some choice!

In residential services particularly, increasing frailty, illness or dementia limit engagement, autonomy and choice, often making them impossible or at best a tokenistic mechanism for impression management. Kindness and empathy become more important than autonomy and choice.

Warnings: Some of these problems are explained in an ABC News article Aged care ratings do not tell what you need to know about Australian nursing homes (2 May 2018) which tries to warn families that "you want to look beyond the glossy brochures".  It then tells them “But you can't.” because you are “likely be told there isn't any data. At least not any you're able to access” and even if there is some “it's likely no-one will tell you”. Instead they “will point to a near perfect federal accreditation score” which doesn’t help much as they are all perfect.

Choice and the market: The aged and their families lack the knowledge needed to evaluate data when making decisions.  They have no experience and so no confidence in their own abilities.  They may turn to consultants that make a living by offering advice. These consultants may be motivated by the market themselves and this will influence the advice they give.  But worst still, these are not the people who go into the nursing homes and see what is happening.  They rely on data from the Quality Agency which is of little value, and on that supplied by the provider, which is usually advertorial.  

Example:  "Age is not a Disease – Aged Care does NOT belong in the Healthcare Domain" 

Translation: If ageing is not a disease, then you don’t need expensive trained nurses.

Those who actually care for the aged can only wonder what the multiple system degenerations and failures that lead to ageing, to frailty and ultimately death are.  Surely people enter a nursing home because their multiple failing systems, the diseases of the aged, can no longer be managed at home.

Their diseases are more complex, more difficult to diagnose and harder to treat than in most other sectors of health care. 

We are expected to believe that these diseases are magically cured when you enter a "Residential Aged Care Facility" as a "consumer". 

I have never seen anyone die of 'old age' although they often have so many chronic degenerative diseases that you cannot attribute it to one – or trying to make a single diagnosis becomes academic.  Understandably the untrained person looking for a new illusion might see a frail elderly person dying as simply old age and we will often say so ourselves when we cannot sort out the complexity and it is no longer necessary to do so. 

We need to look more closely to see why this illusion has become so powerful and persistent.

A message from the USA: Andrew Turner was a very successful, credible and admired founder of Sun Healthcare.  This US provider of aged care, which had grown into a giant over only a few years, entered Australia in 1997.  The enormous success of Turner’s company was based on cost cutting (ie poor staffing) in looking after the aged who were not profitable while at the same time spending to exploit a loophole in the DRG payment system to provide vast amounts of profitable post-acute care to healthy patients who did not need much nursing.  Consultants in the USA advising on international expansion advised company executives to ‘play on politicians pain’. Turner’s assertive recipe that he sold to politicians in the USA and then Australia was that aged care was costing far too much. Government should butt out of aged care and leave it to the market.  There was plenty of fat in the system.  You did not for instance, need nurses to shower and wipe bottoms. 

We can understand why this was so appealing to politicians planning for the aged care bulge.  Turner had no doubts about his own genius and the corporate staff in the company’s impressive headquarters worshipped him. He created a deep impression on politicians and our industry.  Politicians were soon saying the same things. 

The illusion that aged care was not health care and you did not need nurses has dogged aged care in Australia ever since. For example, in February 2000 (then) Aged Care Minister Bronwyn Bishop considered that middle-aged women providing tender, loving care was all that was required to care for residents.

We have seen this asserted and expressed in the words used by industry and politicians and in multiple actions over the last 20 years.  Their resistance to recommending minimum staffing levels, to requiring registered nurses and the steadily reducing numbers of trained nurses in the sector can all be seen in the light of the persistence of this illusion within the discourse, although it is less frequently proclaimed publicly.

Sun Healthcare was soon in trouble in the USA and entered bankruptcy in the USA about a year after entering Australia amidst allegations of fraud and poor care.  It failed a probity review in Victoria and entered bankruptcy here.  Sun rapidly dumped Turner and his credibility in the USA was destroyed - but by now this self-serving belief was firmly established in Australia and its origins long forgotten.  Turner had no insight, blamed those who succeeded him and continued to market himself as a world authority on aged care.

This illusion was being embraced in 1997 when the Aged Care Act was passed and all restrictions on staffing lifted.  It has been asserted by leaders in the industry and welcomed by the far right in politics. 

In 2014, aged care was moved out of the health department by the Abbott government.  Geriatrician, Dr Mykyta despaired and described health and aged care as "like ships that pass in the night but don't get close to hailing range".  Eventually common sense prevailed and it was moved back. 

Despite the increasing numbers of publicly reported failures to provide proper nursing care, in late 2016 an MD of a prominent provider, strongly asserted that “Age is not a Disease – Aged Care does NOT belong in the Healthcare Domain” .  Bizarrely, many see health care as 'medicalising' aged care and so stripping away quality of life.

In summary

At the first Aged Care Workforce Strategy Taskforce Summit (Dec 2017) held in Melbourne, it was difficult to believe that this issue of whether "Residential Aged Care Facilities" were a home or a hospital was argued again there but I heard that it was.  Some came away thinking that it had to be one or the other and that having on site medical care somehow might compromise quality of life, which was more important.

This is one of those illusions that won’t die because it is profitable.  It justifies the argument that you don’t need expensive nurses. Challenging it challenges business practices and success.  It was how Sun Healthcare made much of its money.