Introduction
In a recent webinar from the Long Term Care Community Coalition in the USA titled How Fear of Retaliation Scares Residents Into Silence (18 Apr 2023), Eilon Caspi described his detailed research into this problem. He shows just how widespread the problem of retribution when residents complain has become in the USA. This is a valuable and important contribution. He calls for more research, education, regulation and protection of residents. He described the way the industry rejects these sorts of finding and resists regulatory efforts.
I was stimulated, not by his very disturbing findings, which are not a surprise to those who have studied this sector, or by his call for more research, but by his primary focus on education and regulation to protect the residents and address the problems when identified. I felt something was missing and decided to write about it.
That sort of mistreatment of residents is of course a well-recognised but ignored problem even in Australia. Its full extent has not been revealed here. It is particularly significant in Australia now because our star ratings are being weighted to give far greater emphasis to resident feedback. They are doing this because they claim it is not self-reported by nursing homes and is claimed to be objective! There are many reasons why it is influenced by the nursing homes and is not objective. This is an important one.
Caspi’s findings are not a surprise, but I was worried by his thinking about the problem and how to solve it. Instead of asking how and why a situation like this has arisen to see what could be done about it, his response was for more regulation and education in an attempt to keep it under control and deter it. The USA, UK and Australia have been responding in this way since the 1970s and yet the problems simply get worse!
The Royal Commissions own Background Paper 8 ‘The History of Aged Care Reviews’ was released at the same time as the interim report in October 2019. It identified this same problem and concluded in its final sentence that “The overarching question that arises is why, after all these reviews, the aged care system still fails to support an appropriate quality life”.
The Interim Report identified “deep and entrenched systemic flaws” that needed “fundamental reform” describing it as “whole-of- system reform and redesign”. It clearly understood the problem. Instead, the failed system is being renovated, something which Commissioner Justice Pagone, who had replaced justice Tracey strongly disagreed with in the final report. The promise made in the Interim Report has not been met. This is not the place to explore how and why that happened, but we should not accept it.
Some thoughts
What Caspi describes is clearly a cultural problem. Most people do not behave like this normally. We can compare it with other examples where residents have been abused in shocking ways because the conduct is so similar.
Caspi does refer to this occurring in institutions in the past and that certainly was the case with several examples in other areas like mental health. In Australia it also seems to have occurred to the UK orphans who were sent to Australian institutions after WWII.
There is nothing new about this. Like Australia, there were serious problems in aged care in the USA in the 1970s which were probably contained but not addressed (I did not study this). They recurred after free market ideology became dominant in the 1980s. Major scandals in the late 1990s saw many companies become bankrupt when their fraudulent activities were blocked. The response was regulatory. The underlying problems have never been addressed and the perverse pressures generated in this sort of market remain.
We have written many web pages about these failures and I will give some links at the end of this discussion.
As Caspri described in the USA, industry and government in Australia have dealt with this sort of exposure as well as other examples of system failure that became public, by denying them or calling them rare exceptions. Clear red flags pointing to a flawed system have been repeatedly ignored.
There are many ways of looking at our problems and analysing them. They provide windows into what is happening.
A different approach: While education and regulation are necessary, my background leads me to look at Caspri’s findings as a symptom of what is going on. We need to ask what is happening in our nursing homes that makes people behave like this and can we do anything about it?
If the underlying disease responsible is not addressed, then the visible manifestations of a fractured system with fractured relationships is simply suppressed by regulation and even by education. Instead of solving problems, the situation just gets worse. Perhaps we should ask whether the sort of regulation and education we are employing could be compounding the problem.
More regulation clearly requires more complex processes and structures to be put in place which puts more pressure on management and from them on staff. It increases the overall costs and leaves less for staffing and care. It does little to address the underlying cultural problems and fractured relationships revealed by all this.
When employees are motivated by recruitment advertising and education and they then find themselves in a working environment where their humanitarian efforts are not valued, they soon become alienated and angry – a toxic culture develops. The residents can be targeted. That too might aggravate the problem.
This does not mean that we do not need good regulation and education, but we need to look at what we are trying to accomplish. These may not be the best ways of addressing the problems.
Examples:
- The classic example is the Winterbourne facility in the UK where staff abused residents in packs and several were jailed. But in doing so the judge “condemned Castlebeck (the corporate owner) for the way Winterbourne View was run. ‘It is common ground in this case that the hospital was run with a view to profit and with a scandalous lack of regard to the interests of its residents and staff,’ he said. ‘A culture of ill-treatment developed and as is often the case, cruelty bred cruelty. This culture corrupted and debased, to varying degrees, these defendants, all of whom are of previous good character,’ he added”.
Source: Winterbourne View care home staff jailed for abusing residents The Guardian, 26 Oct 2012 - In Australia a worker was filmed systematically abusing an elderly man – appalling treatment. The magistrate accepted that “his offending was out of character”. The facility had changed “from a family-operated facility to being operated by a management group and there was a change in support for the staff” and he was “somewhat demotivated and disillusioned at the time, and therefore under quite a bit of stress”.
Source: Cxxxx Lxxxx stressed about work when he abused Cyyyyyy Hyyyy at nursing home, court documents show Adelaide Now, 27 July 2016 (behind paywall)
Available and tells story: Hidden camera captures abuse, apparent suffocation attempt of elderly man in Adelaide nursing home: The Advertiser, 26 July 2016 - At other times nurses in Australia have used residents callously in games including taking photos of their genitals to play a guessing game for others to identify whose they were. In another instance staff taunted a resident by telling her that her husband was having an affair.
Source: Nurses fired for abuse of elderly residents Channel 9 News, 6 Mar 2011 - The training of nurses has also changed. TAFE courses have been privatised and contracted out to the market. There have been multiple scandals where students and government funding have been exploited in the pursuit of profit and where training was so poor that many degrees had to be withdrawn. A 2015 article on Aged Care Crisis web site written by an enrolled nurse describes the lack of empathy and compassion that she had observed in the sector. This educational atmosphere and this sort of training is likely to play a role in creating this situation. There are no role models to create a genuine vocational mindset.
Source: The Neglected Old Man - In the USA, the St. Louis Post Dispatch described what was happening to care, to staff and to the US aged care system in 2002 and it is similar to many other reports. They quoted Professor Charlene Harrington who has spent her life studying these developments in the USA. She said “As you have it now, we're stuck with an unhappy, demoralized work force and not enough of them. Realistically, it's a hopeless proposition to improve the quality of care". Caspi shows that it is still happening. It also sounds like Australia in 2023.
Source: Woefully inadequate staffing is at the root of patient neglect Louis Post-Dispatch, 14 Oct 2002
We have written more about this cultural problem on a web page titled 'Conflicting cultures':
Trying to explain this: Perhaps a simple way to look at what is happening, is to look at the different ways in which we conceive of things as reflected in the language we use.
We once spoke about nursing homes, a place where the frail people whose bodies or minds had degenerated so that they could not look after themselves received nursing care from professional nurses with vocations. They are now called ‘Residential Aged Care Facilities’ (RACs) where residents receive ‘services’.
In Victoria in the 1980s, all care was provided by trained nurses and not by nurse aids. While residents are now much frailer with many more complex problems only about a quarter of the care they receives comes from trained nurses.
Nursing and other caring professions used to be ‘vocations’. Those who provided care were motivated by empathic community and professional values. They interacted and engaged with the public, building identities and respect in the process.
This has now become just a difficult and unpleasant job like any other and they are part of a workforce. Staff no longer interact with the community in the same way. Their values and their conduct is not admired and they do not develop the same caring identities. Trained nurses find this challenging and vacate the sector giving it a bad reputation.
Senior management are often not interested in the welfare of their staff or the way that care (now 'services') is provided. Their primary concerns are the generation of profits from the residents and containing the costs of staffing. Nurse academics have studied the impact of this sort of management on the way staff think.
Social scientists who have examined the cultural conflicts write about cultural conflict, paradigm conflict, role conflict, alienation and the toxic cultures that develop when this happens. Aged care is a good example of all this but those sorts of analysis are not seen as credible.
If we look back we can see that, as Caspi indicated, these problems developed in the past in mental and other institutions which were relatively isolated from the community. We have now created that situation in our nursing homes.
How did this happen?: This change has been happening for a long time as free market ideas developed by a small group of economists in the 1940s slowly gained traction. It has accelerated over the last 40 years as economic rationalist (free market) thinking became dominant and alternative types of markets were forced to conform. A one size fits all marketplace was applied regardless of the consequences.
In the 1990s a leading Australian doctor commented that “mad cow thinking was being transfused into every vein of our society”. Mad Cow disease spreads from cows and we get it from eating beef. It was a problem at the time. It infects patient’s brains and those infected behaved bizarrely. What was happening made no sense to those for whom caring was a vocation.
One of the consequences of free markets has been that our communities, what we called ‘civil society’ has been pushed aside and no longer influences thinking or behaviour.
A well organised civil society has many points of view and it also has the power of numbers. Citizens are involved in the affairs of the community and the country and act to counter irrational ideas and beliefs. This free-market belief system rejected any sort of oversight, particularly from what it called ‘the collective’.
As Caspi explains the recipients of care and their families are powerless. But the community (the collective) who should have the power to act on their behalf and protect them has been pushed aside and no longer has the interest or the power to do so.
Our communities, the people other citizens meet regularly, talk to, and try out their ideas on, are the most effective regulators because they challenge beliefs. They do so before they are applied so prevent problems from developing and this is much less costly. When problems do develop, they are the first to recognise this and apply pressure to stop. That no longer happens. Formal regulation is only needed when someone is recalcitrant.
Treating the disease: The argument is that the way to treat this social disease is to rebuild civil society and involve citizens in aged care by giving them a more important role. They become involved and build altruistic identities there.
They need to be involved with staff in overseeing what happens so that good care is valued and poor care stigmatised. Good staff become role models in the community and the young become motivated to do nursing. It becomes an admired and fulfilling profession. We have suggested ways of doing this.
Its not new: There is nothing new in this suggestion. Early reviews in Australia in the 1970s and early 1980s wanted aged care to be more regionalised. The 1985 Giles report, whose findings of failed care mirrored the Royal Commission’s interim report, advised that local persons should be directly involved in working with staff in investigating complaints. Commissioner Pagone recommended a more limited regionalised system but he was ignored.
The 1989 Ronalds’ report resulted in a Human Rights Bill being passed. It also recommended involved community visitors who would watch over the residents to see they were well cared for as well as an independent advocacy service. These ideas were ridiculed by industry calling it the ‘Community Busybody Scheme’ and they were watered down.
These recommendations if adopted, would have empowered community and created a more balanced system where market excesses would have been checked. This sort of restriction was incompatible with the free-market ideas that were by then accepted by industry and dominant factions on both sides of government.
Appendix: The story in the USA and the UK
As indicated earlier, Caspi’s findings are simply a confirmation that, what has been happening in the USA and the UK for a long time, is still happening and that all the regulatory efforts that have been made have not worked. Both countries differ from Australia in that they have collected much more information and have supervised and regulated more intensively than in Australia.
We now know that while care was steadily deteriorating over the last 25 years, the success rate of industry in being given full marks by the Australian regulator increased from 60% in 2000 to almost 98% in 2016 before the Royal Commission was called. In the USA, only 7% received perfect scores and 20% were found to have serious problems. Who was our regulator protecting?
The mistreatment and abuse of residents in the USA has been a problem for many years as has the ineffectiveness of regulation. An expose using hidden video cameras with an analysis done ten years ago is still available on YouTube: Fault Lines
Shocking mistreatment and abuse in the UK was exposed on the BBC television’s Panorama program in 2014. As in Australia more recently, BUPA was one of the principal owners of the facilities responsible. A survey had shown that “one in three adults who are in residential care or receiving help at home fear abuse or physical harm — that's about half a million people”. So what happened in the USA was happening in the UK too.
- Source: A Buzzfeed report on this is still available “This Is The Shocking Face Of Abuse In Britain's Elderly Care System” Buzzfeed 30 Apr 2014
We have written about the systems in the US and the UK and the problems go back for many years. There are links to large numbers of reports.
See:
- Aged Care failures 2015/16
- International aged care 2015
Going back even further: There were huge problems in nursing home care in the USA at the end of the 1990s. Sun Healthcare, one of the worst offenders was welcomed by the Howard government in 1997. I was alarmed and soon received a huge volume of material from contacts in the USA. Between 2000 and 2007 I contributed to their efforts and tried to warn Australia by writing over 60 web pages about US aged care and the big companies responsible. I quoted representative paragraphs from this material and linked to the originals. That is too extensive to read but for the record it starts at Aged Care & Nursing Homes: Access To Web Pages
The material from the USA and the UK clearly shows the close association between poor staffing and poor care on the one hand and corporatisation on the other. While nonprofits were affected they maintained a separate identity and consistently performed much better. In an upgrade written in 2003 describing several more recent reports I commented “The evidence that care provided for the benefit of shareholders is vastly inferior to that provided for the benefit of patients has become overwhelming”. That web page is shorter and gives a good idea of what had been happening.
- See: Nursing Homes Update June 2001 to August 2003
This difference has been apparent but less obvious in Australia where data collection has been far poorer than in the USA and the UK. Non-profits seem to have aligned themselves more closely with the market and its practices. Non-profits like Southern Cross and BlueCare have reduced their staffing levels to meet benchmarks set by StewartBrown (accounting firm) that were about an hour less (over 25%) than minimum safe levels recommended in the USA.
Private Equity
There is one more twist to the story. In the early 2000s the far more strongly market focused private equity groups started buying up nursing homes first in the USA and then in the UK. They would buy companies that were struggling, make them profitable, and then sell them at a profit leaving the purchasers to deal with the consequences of what they had done. Studies in the USA have shown that their performance is even worse than the large for-profit chains.
They also created webs of companies that worked together to move funds about so that it became easier to indulge in fraud, avoid taxes, manipulate the system and hide money in tax havens. These strategies have been associated with inferior care but have nevertheless been adopted by most large for-profit providers across the world. Their use for tax evasion by aged care companies in Australia was exposed by the Centre for International Corporate Tax Accountability & Research (CICTAR). A senate inquiry followed.
Our submission to the 2007 inquiry into Private Equity warning of the consequences for aged care and other vulnerable services in Australia was rejected. Only a few weeks later, the New York Times exposed what has happened there. Private equity has since become a huge problem in the UK as well as in the USA where there was a recent government inquiry. They have invested in aged care in Australia since about 2006.
We wrote about this at some length in 2015:
- Private Equity (an in-depth analysis)
- In responding to Questions on Notice after appearing before a senate committee in 2021 we addressed a question about these corporate webs on pages 10 to 14.
- We then discovered more problems in the UK and that a very critical US government inquiry into private equity had just completed. We followed up with a
letter giving more information and links but it was not published.
