Analysis of Senate Inquiry: Effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse and poor practices

Discrediting the myth that 'Age is not a Disease' and 'Aged Care is NOT Healthcare'

The report spends a long time discussing the issue of poor care and particularly poor clinical care, and then blames most if not all the failures on the problem created by this myth.  While this issue is very important and the report is partly correct, we suggest that it focuses on a simplistic explanation which plays a minor role at most in causing the problem.   This allows it to avoid the root causes of the problems and the need to confront the failure of the political policies and beliefs of both major parties.

Aged care is not a disease: While it does not specifically spell out one of the early illusions of the free market neoliberal agenda in aged care, it addresses it in its own terms.  The basic illusion expressed by others is that aged care is not a disease but a normal process.  It follows therefore, that aged care is about supporting the elderly and not about providing clinical/medical care.  This is usually called medicalising and that it is claimed compromises care.  Too much bad medicine given by the poorly trained certainly does, but that is not an argument for not providing needed care.

Nursing homes not hospitals: The form that this takes in Australia is the belief that nursing homes are the institutions where the aged are accommodated and their personal needs met.  Clinical/medical care are supplied by others who are brought in to do so.  They are not a responsibility of the aged care providers and have their own regulator.   They should not be regulated by aged care regulators. 

This was put to the committee in different ways by providers and some of the provider organisations.   The committee forcefully rejected the argument and insisted that clinical care was a critically important component of aged care.

For example:  In late 2016 the MD of Seasons Aged Care, a prominent provider, and board member of the industry group LASA strongly asserted that Age is not a Disease – Aged Care does NOT belong in the Healthcare Domain.  Bizarrely, many with views like this see health care not as the foundation for a good quality of life, but as 'medicalising' aged care and so stripping away quality of life. The problem is that medical care is costly and not profitable, so that ideas like this immediately resonate.

The Agency too: Members of the Accreditation Agency's board were drawn from industry.  Its CEO came from the industry body LASA.  Those doing the assessments are recruited from provider organisations - many without clinical skills.  We can understand how the agency would have been captured by this pattern of thinking and would have undervalued clinical skills in its assessors and in its assessments.

The report also creates another illusion by artificially separating clinical from medical care.  It calls the care given by trained nurses 'clinical care' and that given by doctors 'medical care'.  The two are not separable and cannot be handled separately.  That is very unhelpful.  In fact, separating clinical care from personal care is also somewhat artificial. 

What is needed is a continuum of care by people who are working together, although the skills and training of those involved determines what role they play.  Dividing them up into bits is unhelpful.  We can understand why the system has failed so abysmally to supply or detect clinical failures in aged care.

But we have a different explanation.   The committee's explanation is only a small part of the story.

Where the report failed

The explanation is inaccurate: The way clinical care is downplayed has been an issue that Aged Care Crisis has addressed in several of its submissions. This is the first time it has been addressed by an inquiry.

The explanation offered by the senate committee that this situation came about because the distinction between hostels and nursing homes was abolished in 1997 is of doubtful significance. At best it would have had a minor influence.

The real problem: This explanation serves to divert attention from the real cause which was the commercial priorities of the big companies.  The real problem was commercial because the way money was made from nursing homes in all countries was by keeping costs down.  This meant fewer nurses.  

Justifications were required and a new illusion developed to make it legitimate.  Dysfunctional systems are built on layers of illusions as new ones are needed to support the belief systems used when they are threatened.

In the late 1990's there was intense enthusiasm in the USA to expand globally, partly because government in the USA were cutting back on some money making strategies.  Private care in other countries provided huge opportunities because it was poorly regulated. 

Market strategies:  Consultants were soon offering advice like this:

In aged care that meant persuading governments that you did not need nurses – the biggest cost.  Companies would offer to sort that out.   Over the years since then we have seen some global business organisations advising clients by promoting the idea that aged care is not a disease and it is not about medical care – sometimes describing the problems with medicalisation.

A more direct source: One very charismatic US businessman had built an meteoric nursing home empire by 'double dipping' in providing step down care that hospitals had been paid for in his nursing homes and charging again. Politicians in the USA had been struggling with nursing home costs for years. In the 1980s they saw markets as the solution. His very successful sales pitch was that there was plenty of fat in the system. You did not need trained nurses to wipe bottoms and shower people.  Government needed to butt out and leave it to the market to sort out.  This was music to politician's ears and his claims to be a visionary aged care authority were unquestioningly accepted.

He came to Australia where he met with and was welcomed by politicians and the business community.  Both were soon echoing his ideas in their public statements.  He bought some small hospitals suitable for step down care and the minister announced plans to revolutionise health care using step down care.  He invested in a small company Alpha Healthcare intending to expand into aged care. 

The Foreign Investment and Review Board (FIRB) had been supplied with information.  In spite of its negative report Sun Healthcare was welcomed by politicians.  But authorities in the USA were waking up to what was happening in their industry. Things soon unravelled when the USA stopped the double dipping.  The US company was charged with fraud and some US states blocked it from investing because of poor care. It failed a probity review in Victoria and it was blocked from investing there. 

Sun Healthcare entered bankruptcy in both countries.  It dumped its discredited founder.  He continued to protest his infallible vision but no one was listening.

Applying these ideas: These appealing ideas developed a life of their own in Australia.  They fitted well with the free market neoliberal ideas that were being introduced.  Aged care ministers and politicians have repeated the myth in various ways over the years as have many in the industry.  

Tony Abbott became Minister for Health while Sun was in Australia.  When he became Prime Minister in 2014, his government moved aged care out of the Health Department and into Social Welfare, a clear indication of what government thought about this.  As one geriatrician put it health and aged care passed each other 'like a ship in the night' - without any contact.  It was a move that created problems.  Aged Care was returned to the Department of Health after Abbott was defeated. 

In 2016, a board member of LASA was still insisting that "Aged Care is not a disease" and in 2018 the same sort of arguments were made to the senate committee, which for the first time explicitly rejected them.  That is an important step if it is accepted by the rest of parliament but, like the poor staffing, it is a symptom and not the root cause of the problems that the senate report claims it to be.

Protecting the belief system

Every belief system protects itself and aged care is a challenge to both neoliberalism and managerialism to which both major parties have been  committed.

To have further denied problems was not credible.  But in doing so believers instinctively protect their beliefs and maintain control.  Most of the recent inquiries and reviews but particularly the Carnell/Patterson review have been highly selective in what they say and the material they quote.

Example Braithwaite's criticisms:  Both the senate and Carnell were supplied with detailed information about John Braithwaite's strong criticisms of our regulatory system and the belief system that was responsible. He is one of Australia's leading academic criminologists and has spent much of his life studying and comparing regulation in several countries.   Carnell referenced and spoke of his theories supporting them but did not mention his criticisms as all.  The senate report called specifically to address failures in regulation did not mention him or his criticisms in their reports.

Example an empowered visitors scheme: The Public Guardian in Queensland, and the Public advocates in Queensland and Victoria all strongly advocated for an empowered Visitors scheme in aged care in submissions to this senate review. They had experience with such a system and it had worked well. Our submission strongly supported them. This would have brought in an outside group unlikely to support the belief. Government and industry would not have been able to control this potential threat.

While the advocate and guardian submissions and their findings were quoted to support the finding of failed care, their suggestions (and our support) were totally ignored in both their February 2018 Interim Report and their April 2019 one.  They did not even have the courtesy to explain why that would not work.  Doing that would have opened the idea to public discussion which they would not want.

An inadequate regulatory response

The report comes in behind and uncritically accepts and praises the essential elements of all the previous reports.  They mention the Carnell/Paterson report, the report of the Aged Care Taskforce (which was industry-led and based on another 'voluntary code of conduct') and the Aged Care Minister's new reforms to consolidate the regulators under one umbrella. 

It makes some criticisms of the way it is being done and suggests how it might be done better.  These changes might well result in some improvement in the regulatory effort, but it will not address the real problems in the system and they will resurface in time. 

This was a review dominated by Labor.  We worry that this mirrors what happened in 2007, when in spite of its criticisms in opposition, Labor put aged care on a back burner and kept it out of the public eye as much as it could for several years.   To do otherwise, if it wins the coming election with a narrow majority, will expose it to an emotive attack from the current government when in opposition.

Paradigm paralysis

Criticism of Report Recommendations: This report is set within a top/down managerialist control and structure framework. It uncritically accepts and fails to confront inappropriate neoliberal and managerial ideas.

Those who have made it clearly identify with these patterns of thought and are struggling to make existing structures work.  There is no fundamental change here.  There is simply more of the same and the same people remain.  For them this is how it is done – a process driven system, order and tight control.  There is only one way. This is a political system that claims to value innovation here. This is paradigm paralysis.

The report restricts input and influence to those whom they see as credible and excludes any that might rock the boat and be critical.  It creates a system that seeks to control and exclude. The likelihood that we will see more real transparency and any sort of distributive justice is remote.  In a system that embraces distributive justice there is input from many points of view so that process and outcome are balanced and not biased by only one perspective.

Neoliberalism, managerialism, markets and freedom

It is useful to look back at the thinkers on whose ideas the Neoliberalism they are defending was built, Friedrich Hayek, Milton Friedman, Ayn Rand and the groups they formed like the Mont Pelerin Society.  

There is the unanimous condemnation of 'the collective' which soon included society itself as well as any other sort of control exerted over the excesses of the individual. If we think of democracy as reflecting the will of the collective, of the people, then it too has been in the firing line although they skated around this when challenged. Collectivism they claimed inevitably resulted in 'totalitarianism' and the loss of freedom.

Mankind was seen as driven entirely by self-interest.   Selflessness and altruism were specifically condemned as evil by Rand.  They condemned social justice and saw social responsibility as socialism.  Both were a threat to a free society.  They saw free and unrestrained markets as the only road to freedom and considered that they were self-correcting provided they were not interfered with – ie regulated or controlled.

In the 1980s managerialism, an existing belief adopted neoliberalism as its own. It incorporated ways of controlling individuals and society in the interests of the market or government.  Employees and citizens were bound to and became servants of the organisation.  The economy became more important than the citizens it should have served. 

This free market system originated in a philosophy that embraced individual selfishness and rejected social responsibility and the society whose members it served.  In 1997, it became the vehicle for providing care. Society and its members (potential threats to freedom) were even denied access to accurate data.  We should not be surprised at the consequences.

We should ask ourselves about the freedom from fascist and socialist totalitarianism that these believers promised. In 2002 George Bush Junior claimed Friedman's ideas had delivered freedom! But surely what we have experienced in aged care is a form of market and economic totalitarianism and this carefully managed report confirms that.

In the book 'The Human Costs of Managerialism', which they edited in 1995, Stuart Rees and Gordon Rodley argued that we were being enslaved and that our humanity was being destroyed.  They included a cartoon from Leunig, which makes the totalitarian point and shows how readily citizens embrace dangerous beliefs when their sources of information are controlled.