In her submission to the Royal Commission which she made public, Senator Fierravanti-Wells has savaged her colleagues in the liberal party and blamed them for the crisis in aged care. We admire her courage and her integrity in doing so.
As a shadow aged care minister she drafted aged care policy prior to the 2013 election. At Aged Care Crisis we have been very critical of her party's policies, but in her submission she has made proposals that begin to move policy debate in a more sensible direction. We welcome that.
A submission from a minister that drafted policy for her party is an important document, particularly as she is now writing from her own recent personal experience of aged care. This is doubly so when she blows the whistle and claims that the failure of her colleagues to implement the policies she designed for the 2013 election was responsible for these failures. When these politicians were elected, they bypassed Fierravanti-Wells and appointed someone else to the aged care portfolio. She suggests they betrayed the citizens who elected the party by not pursuing these policies.
Like Aged Care Crisis, the minister urges major structural change and we were surprised to find that despite some differences she is moving in the same general direction.
Errors of fact - qualified criticisms
Senator Fierravanti-Wells incorrectly blames only the Abbott government for all the problems in aged care. The problems were a consequence of policies developed in 1997. They were predictable, were predicted and became apparent within a very few years.
But she is correct in that the Abbott government and the policies pursued by its ministers, Andrews, Morrison and Fifield fully deserve her ire because they were responsible for the further rapid deterioration that we have all seen.
Government mismanagement: The senator claims that the Aged Care Sector Committee was inactive and did nothing. In fact it and its handmaiden, the National Aged Care Alliance (NACA), were very active in pursuing the Red Tape Reduction Action Plan that reduced oversight and in drafting the damaging Aged Care Roadmap, which was energetically pursued. They supported aggressive competitive consolidation through market driven acquisitions. This consumed money intended for care and drove it from mediocre to a national disgrace.
The 2011 Productivity Commission report was also not the solution the senator claimed it to be. It failed to understand the nature of care and the vulnerability of residents and families. The 'Living Longer Living Better' 'reforms' based on it were almost as ineffective and harmful as the Aged Care Roadmap she blames. Both pursued neoliberal free market aged care policies and ignored society and the critical role of communities.
The senator is very critical of the disastrous decision to transfer aged care from the Department of Health to Social Services. She describes the costly shifts in public service staff from health care to social services and back as aged care was moved about and the numbers of staff significantly reduced.
She is also describing the escalation of Howard's policy of small government. Erosion of the public service left it so ineffective, that it had to rely on a revolving door of industry leaders, and on contracted marketplace consultants to collect information and make policies for it.
Whose advice is more valuable?: The senator's background on the board of an aged care provider and in a party that embraced free market principles led her to boast that she had visited and talked to providers across the country. What she perhaps did not do, was talk to local councils and representatives like Clare Hargreaves who gave evidence to the Royal Comission on 19 March 2019. Hargreaves explained how local councils had been successfully providing and managing aged care for years and were well placed to do so. She described how disruptive government policy had been for the service they provided.
Constructive criticisms with our qualified agreement
At the same time as her government's competitive consolidation policies were driving poor practice and profit seeking behaviour, there were major cuts to public service staffing and capacity. The remaining staff were expected to control these aggressive competitors by inducing them to self-regulate using governance processes to 'steer' themselves from aggressive opportunism to saintly altruism. That was never going to work and it has not.
Regulatory ineffectiveness: The senator is very critical of the impact that ineffective regulatory compliance (accreditation) has had on skilled direct care nursing staff and the care they provide. Badly needed clinical staff are diverted from care to do extensive audit documentation.
We agree that accreditation is not a regulatory process. It wastes valuable staff time. Unfortunately since regulation was abolished in 1997, it has been the only outside oversight there was so we have had to depend on it.
We consider that less onerous accreditation and governance can be beneficial in steering the willing to good practice when it is in their interests. They will only do so when the market is competing to meet the requirements and the standards that are set by the community. To accomplish this the community should have over-sight and the capacity to exert strong pressure when required, and ultimately the power to expel those who fail to meet their expectations.
Regulating effectively: There are far more effective regulatory processes to constrain bad behaviour and the most powerful is the criticism and ostracism that responsible citizens exert on those who show a tendency to ignore their values.
The industry needs to recognise that communities are ultimately responsible for the welfare of their members. Those providing services are acting as agents of the communities they serve. Industry's interests are best served by working openly and cooperatively with communities to collect the data that they both need to assess the service and provide good care. Government's role is to build and support community with backup regulation. It should not undermine it by doing things that communities are better at.
Plans for the future, the senator is getting the message
The senator describes rapid growth in the number of elderly needing expensive care at the same time as the number of younger income earning citizens who must support this expensive burden is falling. Worse still the expectation that children will be available to care for elderly parents more cheaply at home is unrealistic because in the free market, both couples in families now have to work to support their families. Funding will be limited.
These are issues that communities must confront and adapt to. Politician's failure to address this problem over the last three decades shows that they are incapable of doing so. The senator does not have a viable solution.
Funding aged care: Fierravanti-Wells documents the waste of valuable staff time in addressing ACFI funding requirements. We agree. It is a market based approach where care must follow the money and needs are overlooked. We advocate for a community service where money follows the care needed. The community and their local governments are in the best position to manage this.
The senator presses for equity by making aged care a part of the Medicare system including co-payments - paying for care on a per item base. We strongly support the way she is pursuing equity. Raising money by Medicare or superannuation style insurance meets equity requirements and is long overdue. We worry that a centralised system paying per item of service can still be subject to perverse profit pressures. Fierravanti-Wells advocates for a needs driven system, but those needs should be driven by community not market.
We argue that care and staffing payments should instead be quarantined and protected from profit pressures as they were prior to 1997. We agree with Hargreaves and the late Professor Hal Kendig that local councils working with their communities are in a much better position to decide what care is needed. They can contract that care to the agents they select to provide it.
Staffing: The senator's submission correctly identifies the serious deficiencies in medical and nursing care. We agree with her that the health and aged care systems should be closely aligned and work as one system.
Who should control aged care: The senator argues that reform should come "in actual partnership with the sector", but that has been happening for 20 years. Instead it should come in actual partnership with communities and civil society organisations because this is where the values needed in the sector are generated and maintained.
She claims that the aged don't want to be "passive recipients of service" and want to be able to choose. Twenty years of market policy have failed to do this. It requires a civil society and responsible citizens whose only interest is their welfare to ensure this happens.
Aged Care Hubs: The senator advocates for aged care hubs within communities. This is not new and we strongly support it. The potential advantages are real. But there is a strong risk in the senator's market led model that this could simply become a new way for neoliberal ideas and managerialism to spread ever deeper into our society and into our psychological DNA. The power remains with the providers who have so strongly supported the system we have.
The problem lies in the structure. The senator is to be congratulated for moving the system close to the community and serving them more closely. This has been the first time a major political party has done so. But the system she advocates remains firmly in the hands of the providers and their managers and the community are not empowered to hold them to account.
One of us first formally proposed the principles for a community aged care hub to the Productivity Commission inquiry 'Caring for Older Australians' in 2010. It was not supported. The idea of a medical driven and managed aged care hub was advocated by Older Australian of the Year, Professor Ian Maddocks in 2014.
We supported it because the medical profession have the power to constrain unconscionable behaviour and eject those who transgress. We have continued to advocate for a community driven aged care system managed through a local hub system.
There are historical precedents:
- The 1975 Coleman report recognised that because of its complexity and variability, aged care was best managed by local and regional governments. Coleman proposed Seniors Community Centres with maximum local public participation as well as local volunteer and organizational support.
- The 1982 McLeay report considered that the Commonwealth were too far away and incapable of managing this system which needed to be local.
- The 1985 Giles report went further by recommending a front line complaints handling and regulatory "nursing homes standards committee within the community".
- The 1989 Ronalds' report recommended an independent community advocacy system as well as empowered visitors with the powers necessary to watch over residents and work with providers to address issues.
These developments were abandoned when industry and government adopted neoliberal ideas. Management and regulation were taken over by the Commonwealth, marketised and centrally managed along neoliberal lines.
It is time to bring all this together and create a cooperative local hub system where local government and community can manage aged care services. Here they can work closely and cooperatively with their agents the providers, the medical profession and any other services needed. Together they can pursue common objectives. Such a system would have the local checks and balances so lacking in the present system.
