Time to make aged care accountable.
Accountable to who?
To citizens and their communities
An opportunity missed: Aged Care Crisis attempts to persuade the Royal Commission
Aged Care Crisis position
A big problem to address - not just aged care
Aged Care Crisis and its members have been studying what has been happened in society as well as health and aged care.
It has consistently maintained that:
- Aged Care is one of many similar problems that have developed over the last 30 to 40 years. They are not restricted to aged care or to Australia. The root cause of all of these problems lies in changes to society, to markets and to governments, as well as to the relationship between them.
- These changes have seen the rise of markets and free market thinking, and the decline of government and society. Government serves industry rather than the society that elects it. Society has been pushed aside and allowed to wither away.
Margaret Thatcher is claimed to have said 'There's no such thing as society'. As one of us warned in a 2004 lecture “Somehow we have allowed the marketplace and those who live in that world to set themselves above society”.
- Society has played a vital role in teaching us to behave responsibly, care for one another and cooperate in making life better for one another. It is the cradle for the beliefs we have, the relationships we form and the trust we have in one another.
While it protects our freedom it confronts, controls and sanctions those who might harm others or society itself. It admires and praises those who serve others and despises selfishness. It holds markets and government to account ensuring that they serve us and act in our interests.
This change has had a profound impact on the way society functions, the sort of people we are, the way we think and the way we behave. - the fabric of our lives. Societies across the world have lost the capacity to control the excesses of individuals, markets and government.
- We know that when we are sick and have multiple symptoms and multiple organs affected at the same time, there will be a single disease responsible and we need to diagnose and treat it.
The many failures in our societies have occurred in markets where there are vulnerable people or vulnerable employees. Their trust has been abused and they have been harmed. We do not need a highly trained doctor to diagnose this disease. Its glaringly obvious to anyone who has the courage to look, that society has not been there to check the excesses of the selfish and protect the vulnerable.
- Treating only the visible problems in each failed system may relieve the symptoms, but the disease continues to progress. The symptoms either recur or the disease pops up somewhere else. It is increasingly obvious that this is what has happened in many failed systems including aged care over the last 20 years. We have had over 30 aged care inquiries that have examined the symptoms, but ignored the problems in our society.
- The argument is that to address the many failed systems including aged care we need to repair a badly damaged society that is no longer in control. It needs to be rebuilt and empowered so that it can do the important things that it is good at and that functioning societies depend on.
This would be best done by giving communities and their members a central role in managing and watching over the system, particularly the sectors that are vulnerable.
Over the last 12 years the focus of Aged Care Crisis’ advocacy has been on suggesting ways of doing that in aged care. We have urged multiple inquiries to do so.
- Aged care has suffered more than any other sector. Senior citizens have been neglected and abused. It is also better suited to initiate these reforms than any other sectors because every one of us gets old. We are all potential victims of neglect and abuse. Care is provided in our communities and our homes so we can easily become involved.
Q: The BIG Question: Did the Royal Commission diagnose the disease and treat it?
Our conclusion: Sadly No! While this Royal Commission’s report makes useful and credible recommendations that will make a difference, it is at its very heart, deeply flawed. it ultimately fails Australia and its citizens.
The Commissioners identified the symptoms and are planning to treat them energetically. That will be good palliation and we will all feel better, but the disease will progress in the background and then probably resurface in another 5, 10, 15 or even 20 years.
That is likely to happen unless we as citizens and caring professions refuse to accept what is happening and seize the opportunity. The situation is still fluid. We can change this and ensure that our communities can be involved and in control provided we get our act together and use our collective power to insist on it.
Q: Another big question: Why did no one warn us years ago?
Answer: Simple things become more complicated the harder you look. This is not the first time something like this has happened. Experts who study society and human behaviour did look and realised what was happening. They and those who had seen this happen before, tried desperately to warn citizens.
The new ‘reformers’ had the bit in their mouths. Nothing was going to stop them and they stomped on anyone who got in their way. The warnings were ignored.
Q: How did these obviously genuine and intelligent Commissioners ignore something so obvious?
Answer: This is well recognised. It has happened many times before and social scientists have studied it. There have been over 30 previous inquiries that have behaved in the same way. What has happened is described as ‘wilful blindness’ and sometimes as ‘strategic ignorance’. When things are too challenging our brain shields us and we don’t see them.
What can we do?
We can use our collective power to harness these wild horses and control them. These markets and governments that have so badly deceived us and allowed our parents and grandparents to be abused and neglected must become directly accountable to our citizens and communities. We must be able to decide who we will trust to look after our parents and ourselves when we are old and frail. We must be able to decide what we will do with those who betray our trust.
On a related web page Why society has withered: The consequences of policy failure we have attempted to explain what happened in more detail. We document some of the many warnings that were ignored.
In the 1980s inquiries into aged care recommended greater community involvement and control in aged care. We explain why it has become so confronting and difficult to address this issue and empower communities that over 30 more recent inquiries and now these Royal Commissioners have refused to even talk about it.
We also describe how doctors in the USA became prisoners of this system and were trapped in it. Australian doctors saw what was happening in the USA. They got the message and then united using their collective power to resist government pressure and then put those who did not meet their standards out of business. It is a good example of what our communities could and should do.
That analysis is a bit more complex but necessary for a deeper understanding of what has happened. Most readers should be able to get the gist of what happened and understand why acknowledging something that is so obvious to outsiders can be so difficult for those involved.
Aged Care Crisis attempts to address the situation
Over the last 12 years we have been urging inquiries to give citizens in our communities a greater role in aged care and so empower these communities to become an effective force. The arguments and the recommendations we made were ignored.
This page describes our attempts to persuade the Royal Commission to move to a community-led aged care system.
The Terms of Reference for the Royal Commission
Aged Care Crisis (ACC) was acutely aware that what we recommended challenged the belief and faith in markets. We worried that aged care would be examined as primarily a market rather than primarily a humanitarian service. Aged Care Crisis had made many submissions to previous inquiries where this was a problem.
The risk was that insiders who were part of this market system and could not conceive of aged care in any other way, were the only people who would be seen as credible. They would be chosen as Commissioners. Commissioners who thought this way would similarly select witnesses on their perceived credibility, and so not have to address criticism of core beliefs.
Aged Care Crisis made a submission to the Terms of Reference for the Royal Commission and we specifically raised this issue. We knew that many social scientists were aware of the problems in society and were writing about it but they would not be seen as credible. They needed to be heard.
In our submission:
We pointed out that all too frequently "Commissioners have been drawn from what were seen as credible candidates. This was because they came from an economic or other background that aligned with policy”.
In referring to those who would be contributing and making submissions we wrote “Contributors need to be persuaded that the proposed commissioner is not biased by preconceptions that undervalue their contributions”.
We concluded “It is essential that this Royal Commission explore the sector in the required depth and that a broad range of academic expertise with insight into our human condition and the nature of society be encouraged to contribute to the analysis”.
We met with the minister. Others at the meeting supported us when we stressed the need for major structural change to policy. The minister assured us this would be considered.
We do not think that those three issues were addressed. When we later saw that a long-term bureaucrat was a commissioner we became concerned. She had been responsible for introducing ‘governance’ as the preferred way of regulating government departments and markets over the last 15 to 20 years. We also noted that both judges appointed had backgrounds in tax, commercial or industrial law - all marketplace issues.
We later felt that the many social scientists who analysed society critically and who were critical of the free-market model, did not get much of a showing at the hearings redesigning the system.
We realised that this was likely to be another investigation into a failed market instead of into a failed community service. We tried our best to challenge that and hoped that we were wrong.
Invitation to first hearing withdrawn
Aged Care Crisis was invited to provide a witness statement and appear at the first hearing of the Royal Commission in February 2019. One of us put up our hand to appear.
In our statement:
- We stressed that aged care was only one example of many failures in vulnerable sectors. It was part of a wider problem.
- We criticised the industry-led (free-market/neoliberal) model that had been applied to them all.
- We provided data that showed why and how badly aged care was failing compared with other countries, and just how flawed our regulation was. We supplied an attachment containing data and multiple charts to illustrate this.
- We argued that the system should be rebuilt by working with community.
We ended by saying:
"… Society is angry and disillusioned and no longer trusts. A rising tide of anger and cynicism is directed at government and industry on social media. We have to find a way to address this and if we don’t engage communities in finding a path forward, then we will face a dangerous escalating situation. Government is incapable of doing what is required. Marketing using words like ‘choices’, ‘quality’ or anything similar, will increase distrust and anger! …"
"… As individuals, as responsible citizens and as communities we are all responsible for what happens to our vulnerable colleagues. Caring for those in need has always been and still is the responsibility of civil society and in embracing this we express and affirm our humanity. …"
"… Aged Care Crisis have been advocating for a move in this direction for 10 years. We plan to make some suggestions as to how this could and perhaps should be done in aged care but these are not prescriptive. We believe that it is the community itself that should rebuild the system and in doing so it will be rebuilding and empowering itself. In doing so they will be creating a stable platform for addressing other problems. “
We were phoned by Counsel who challenged our credibility and refused to accept the data we had supplied. It was a “who the hell are you?” conversation. Much of the information and data we supplied is similar to the subsequent findings of the Commission’s own research. We were not among those who were selected to appear or participate in roundtable discussions.
Our submissions to the Royal Commission
In our first submission on 8 October 2019, we addressed some issues in the terms of reference, and said “The obvious root cause of multiple similar market failures in vulnerable sectors is a misunderstanding of the nature of markets, the care sector and human behaviour”.
We then addressed all the terms of reference and argued that “care of the vulnerable is primarily a responsibility of the community and its members”.
We attached a detailed 419-page analysis of ‘Why Aged Care is Failing’ with about 650 linked references. This explored what had happened and the policies responsible. It examined policy as well as the societal and psychological factors in the human condition that led to the failures of these policies.
It looked at regulation in the light of the different ways in which citizens controlled one another. We made suggestions for change that included community involvement explaining why this was the best way to control aberrant behaviour and suggesting ways in which this might be done.
Neither that submission nor the analysis have been published.
We responded to many of the research papers and most of the Commission’s discussion papers.
We pointed out that all of the previous inquiries had failed because they had not been prepared to examine and challenge the market-led policies and the theories on which they were based.
We drew attention to the conflicting and incompatible patterns of thought (paradigmatic issues) between those controlling the market on one hand and the staff and community on the other. These resulted in role conflicts and toxic cultures.
We were critical of the Royal Commission’s failure to properly analyse and examine the thinking behind, and consequences of, the free market-based Living Longer Living Better reforms in 2012 and the Aged Care Roadmap in 2015.
Program redesign: Treating the symptoms but not the cause
We felt that proceeding to Program Redesign and asking citizens to respond to proposals and make suggestions without first doing a thorough analysis of the previous system and why it had failed was not only inappropriate, it was also unfair to those responding who would not have had the knowledge and skills to do so. This seemed so elementary and necessary.
It seemed to be taboo for any inquiry to challenge the ideology or policies of a government that had appointed it. Without doing so, the Commission and those who responded would be addressing only the visible manifestations, the symptoms and not the root cause (disease) responsible.
In our response to the Commission’s discussion paper on program design we directly challenged this and criticised the failure to examine root causes.
Extracts from our submission:
There is a stark choice facing this Royal Commission
Will it allow the free market thinking and the policies based on it to continue to dominate the sector or will it restore humanitarian community thinking as the dominant pattern of thinking within the sector? These two patterns of thinking are contradictory and incompatible. This is the paradigmatic issue that we have focused on. You cannot have one and then pretend you are providing the other. Sooner or later people will realise what is happening.
1. Free market thinking: Analysis of the 2014 Aged Care Roadmap and government marketing since 1997, shows that the dominant pattern of thinking (ie paradigm or discourse) adopted in Australia since 1997 is based on free-market principles. Relatively unregulated and uncontrolled markets have responsibility for care.
This model offers choice, control and efficiency as enticements, but often falls short. Its claimed benefits are derived from competition for the patronage of those needing care.
Providers are drawn to the sector by the profits they can make so its driving force is the self-interest of its investors. Relationships are based around services so are transactional. The services are process driven rather than empathic.
2. Humanitarian thinking: The second pattern of thinking is the traditional community one which has stood the test of time. In this one, communities and their members rise to the challenge of caring for those in need.
It is based on empathy, caring relationships, cooperation. social responsibility and a long Samaritan tradition of ‘loving thy neighbour as thyself'. Its motivating force is altruism. Choice and control are not primary objectives but are integral to genuine caring relationships, so more effectively provided.
When providing care, for-profit providers with a commercial interest are not excluded but are required to be reputable and trustworthy before being accepted. They are ejected if they do not embrace community values and provide the sort of care the community requires.
The second critically important question is to ask “Why is it going on?” The interim report fails to do this adequately. As a consequence, the proposals at subsequent hearings address the visible manifestations but not the root causes of the problems.
We would like the Commission to see our criticisms as constructive and our suggestions as an adjunct to what they are doing which we largely agree with. It is what is not being done that concerns us because if the paradigmatic issues are not addressed, these well-intentioned changes will not be effective.
We are deliberately challenging what we see as happening. We feel we have an obligation to make our concerns clear when we think that deliberation about decisions have taken a wrong turning. They will affect so many and for many years to come.
The Commission promised a “fundamental overhaul of the design, objectives, regulation and funding of aged care in Australia”. Unless we change the structure of the system and democratise it so that the hold on power is shifted away from government and industry to citizens, this will not work.
We responded to the Commission’s list of program design issues in the discussion paper. We drew attention to the ways in which local governments and local communities could be involved in managing these issues and be supported and integrated by central regulators.
We argued that this was often the most effective and cost-effective way of doing things. We referred to and quoted from others who had continued to press for a decentralised system and local involvement since it was first recommended in the 1980s.
In a number of appendices, we did some of the analysis that the Commission had failed to do and explained the roles that communities should and could have.
Subsequent submissions: Not all of our submissions were critical and we supported proposals that we considered were useful. We tried to identify problems created by free market thinking and show how community thinking and values would address them.
Direct appeals to examine policy critically
We felt that challenging government policy was taboo. We wrote to the Aged Care Minister and Shadow Minister asking them to release the Commission from this obligation pointing out the reasons why so many previous inquiries had all failed. We wrote “we are appealing to you to publicly advise the Royal Commission that you would be receptive to recommendations that require significant changes to current thinking about the sector and to current policies that are based on this”.
To the Commissioners
We wrote personally to the Commissioners to “Express our deep concern at the delay in critically analysing Australia’s regulatory system and the policies on which they were based to assess their contribution to the problems the Commission has detected”.
We indicated “We consider this to be so elementary and the policies so flawed and out of step with community values and expectations, that we wonder if there is some taboo that bars government appointed and funded inquiries from examining policy”.
We added that “We are not aware of any critical examination of the market-based Aged Care Roadmap or the Living Longer Living Better reforms”.
We also highlighted “the threat of ideological intractability in those with power." We indicated that “When belief and identity are so tightly bound together - - failure is inconceivable, then evidence, logic and even criminal convictions can be denied or explained away. Nothing actually changes until their hold on power is broken”.
In pressing for structural reform, we indicated that “Bottom/Up integration of services would ensure that those most involved in care locally have real input into policy and identify with what was being done. Instead they have been left out in the cold”.
In April 2021, economists from the Faculty of Business and Economics at the University of Melbourne have finally critically examined the impact of the increased competition introduced by the 2011 Productivity Commission report and the 2012 Living Longer Living Better (LLLB) reforms based on them.
They found that “competition isn’t associated with better quality of care or lower prices in aged care” and has been associated with market failure. They found that “the sector hasn’t performed despite years of market-oriented reforms”.
The Royal Commission final report
Embracing a market-led system
This is a report which, while embracing and urging community values of trust and relationship-based care, in practice, addresses a market in aged care rather than a community service. It does criticise government for adopting “an unspoken assumption that market forces should generally be left to themselves”, but it does little to address or change the nature of the market itself.
The report approaches its task in much the same way as previous reviews have done. They attempted to address market failures without challenging belief and policy. This remains a market-led and not a community-led system. The industry are still to be responsible for care and government for regulation. It is not going to be accountable to community and they will not have the power to insist on the sort of care they want for their fellows and themselves.
The reforms to address failures in care, focus on increasing regulation and on governance - a process that has not been effective in aged care, disability care, the banking and financial sector and much else over the last 15 to 20 years.
The perverse incentives intrinsic to the patterns of thinking adopted by market and government create a situation in which the interests of providers and the pressures to succeed and survive create tension between regulator and the regulated sector.
It becomes a war of attrition until an equilibrium is reached where weary regulators cope by turning a blind eye as was revealed in the Department of Health in 2012 when the system was being rorted. Under even greater pressure from the 2014 policy of ‘red tape reduction’, regulatory effort and capacity got worse and worse as revealed by the revelations in the 2017 Oakden scandal.
Entrepreneurial providers with “an eye for the main chance and for the weakness of others” will always seek out loopholes and pressure regulators. When they succeed, others must follow to compete. Even not-for-profits must conform to compete and resist a takeover.
It would be much better to create a system where success comes from being transparently accountable to and meeting community expectations, and not from outwitting regulatory effort.
Commissioner Pagone had an interest in human rights. His first degree had been a Bachelor of Arts. He had been a teacher in the humanities. During the hearings we sensed the different ways the two Commissioners perceived things and saw them disagree.
The final report reveals the extent to which the two Commissioners were unable to agree and at many points in the report they made different recommendations. Their major disagreement was on the structure and control of the system. Briggs wanted it to remain under the control of government and the minister. Pagone saw government as the problem and wanted the system to be managed and financed independently from government.
While many important recommendations are made, this is still a market-led system and not a humanitarian community service to which the market contributes.
The power imbalance remains. Citizens and their communities do not have the power to decide who they will trust to provide services in their communities. There is no easy way for them to replace a provider that has breached their trust with another that will do better. It does not make aged care directly accountable to the citizens and communities it serves.
We examine and comment on the Royal Commission Report on the web page: An opportunity missed: Analysis of the Royal Commission Report.