International aged care

UK: Care standards - Care Quality Commission (CQC)

The fundamental standards for nursing homes set out by the UK's Care Quality Commission (CQC) are clearly often not met. The reports and information available on their website are however, far superior and far more useful than those available from our Quality Agency here in Australia. Here is an example.

Visits are more frequent and unlike Australia, reports are not restricted to 3 or even 5 yearly planned formal accreditation visits. All visits and their findings are available going back up to 5 years so that a facility's track record is accessible.

But as in Australia and the USA, there are many claims that this is simply not working in the face of the pressures in the system. On 22 February 2015, BBC news reported that Thousands of complaints made about elderly care in England and that "Some 14,888 claims about the welfare of care home residents aged 65 and over in 2013-14 were reported to 74 councils, - - - ". They give an example and point to understaffing in the homes and in the oversight body as the problem claiming that this is due to underfunding.

Company bosses from BUPA, a UK global nursing home operator were summoned to a meeting with Scottish health secretary There had been a number of problems in care homes in Scotland and in one, police were investigating deaths.

Following numerous failures in care and intense criticism, the CQC has issued guidelines for family and management setting out guidelines for grannycams (CCTV  videocameras to see what is happening).  It is interesting that a union survey has found that 'three out of five residential care workers feel "relaxed" about visible cameras being installed in care homes'.

The whole idea of government monitoring standards is now being attacked and discredited in the UK.  This is all relevant to us because our Accreditation regime is also sadly even more deficient, if better than nothing.

When a whistleblower who had been a CQC inspector spoke out about its failure to act, the CQC admitted that it was the fear of litigation that stopped it from being effective,

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UK: Financial woes

It is claimed that cost cutting in the UK has left nursing homes short on cash and private equity in particular is struggling.

Private Equity

Private Equity ownership has been a major problem in aged care in the UK. The US Private Equity Group Blackstone is alleged to have left the UK’s largest nursing home, Southern Cross, weak and vulnerable so that it subsequently went under. Four Seasons, nother large private equity group, is struggling and may go under or simply vacate the sector. Care has suffered as a consequence.

See also:

• Southern Cross landlords to take over all homes The Guardian July 11/2011
• Care home companies could be forced to open books to prevent another 'Southern Cross' collapse The Independent 1 Dec 2012
• Southern Cross saga continues as successor care home firm collapse hits Richmond residents  Liberal Democrats 6 March 2015 (LINK NO LONGER AVAILABLE)
• In the spotlight: Four Seasons Health Care and Britain's social care crisis International Business Times 6 May 2015
• Orchid View care scandal coroner to seek public inquiry  BBC News 26 June 2015

A study in which leading Private Equity managers were interviewed, is revealing of the strong commercial pressures generated in the Private Equity sector:

• Private equity and the concept of brittle trust - The Sociological Review, 60:1 (2012)

Nurses salaries

Salaries in nursing homes in the UK are so low that the community and some councils have tried to force the providers to pay a living wage. A National living wage requirement is planned for 2016.

Retirees hock their homes

As in Australia, neoliberal policies are placing an ever greater cost on people who cannot afford to pay and who are using the value of their homes by having a charge placed on their estates so they pay when they die.

Home Care

ITV news describes the problem that providers of home care are having in providing care because of the underfunding. They did a survey of 305 responders (out of 500 asked) who were contracted by local authorities. They indicated that “Their responses revealed a shocking lack of confidence about their ability to provide good quality care at the prices local authorities are now willing to pay.” The full article is linked below.

• Growing Old: Care in Crisis? ITV News 7 Oct 2015

UK: Trapping the unwary

In a highly competitive market the pressure to keep your nursing homes full of people who pay well is very strong. One way is to flood the media with good news stories so that they drown out the bad. PR firms make their money by doing just that for the care homes. The quote below is from a PR firms web site. You need to read the whole of it to see the strategy. They are building traps for the unwary. 

'James' is a family member looking for a home for a parent:

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UK: Criticism of privatisation

There is increasing frustration with privatisation in the UK and many are speaking out about its failures. There was an article by Cat Hobbs, the founder of "We Own It", a new organisation that aims to be a voice for public service users and public ownership.

There are several links to follow and some comment. Privatisation isn't working. It's time for a public service users bill. It is on The Guardian website (5 Aug 2013). It calls for legislation to address the problem. Those interested might like to look and see where it goes.

"THE PRIVATISATION OF THE CARE INDUSTRY; ITS OWN NEMESIS": Ian Cresswell from the Community aged care group “Your Voice Matters” tracks the path that health and aged care in the UK has taken following the drive to privatise health and social services that commenced in the Thatcher and Reagan eras.

In the UK, "privatisation" is used to describe free market solutions because it was introduced into a socialised system. In other sectors they talk about "new capitalism". The article shows how the pursuit of these objectives has ultimately led to the sorry mess that is aged care in the UK. This article is interesting because we have followed that same path but started later and its not as bad as this - yet.

• Money, power and fear rule our care sector. Profit v care. Who wins? Your Voice Matters 1 Sept 2015

Community anger about privatisation: A community group - the NHS Support Federation, has material about privatisation on its website. So concerned is it, that it has set up a separate website NHS for sale.  This is a large, extensively researched website examining the extent of privatisation by big local and multinational organisations. 

It examines the adverse impacts this has had in some detail.  It examines the track record and background to many of the large UK and international corporations which are contracted by the NHS and the problems that have arisen. The list includes Australia's Ramsay Healthcare, SERCO, HCA (the US giant with a record of massive fraud) and several others.  This is a good site for those wanting to look at the problems with privatisation in the UK and in health care more generally.

Some support for this comes from an inquiry in the UK which "concluded that some big hospital groups are making excess profits. HCA was singled out for what was considered to be its dominant position in the capital - - - ."  HCA is a US giant with a history of massive fraud settlements in that country.

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UK: The community collecting information

As in Australia, there are families who have had bad experiences and who have looked around them. They have realised that what they have experienced is industry wide.  Some have become whistleblowers. They have started looking at what is happening, collected information and put it on the internet.

To ordinary citizens scattered around the country, these events seem isolated but when they are collected together, the story they tell about what is happening, and how commonly, is telling and very worrying. Similarities and patterns appear. They show what is happening and why.

One such sight is a Facebook page Your Voice Matters.  They are pressing for CCTV monitoring in all nursing homes.  Another excellent website "The Bank of Home Care" to which a lot of attention had been given particularly to ownership issues has recently been taken down without explanation.  We wonder why?

Ireland has problems too. The Mirror reports people wasting away and dying as carers look on in Irish nursing homes because there are no staff to feed the residents. The food is so poor some won't eat it and there are so few staff that the food soon gets cold. Staff whistleblowers indicate that they have complained to managers but that nothing is done about it.

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UK: Auctioning off granny - the ultimate indignity

In order to save money by placing the frail elderly in the cheapest places, some regional authorities in the UK have quietly gone further than anyone else in turning the elderly into a commodity - a parcel (profit body that will generate a profit after they have been purchased) that is traded on eBay type web sites.

Details of the senior's age and care needs are put onto the website and local nursing homes then bid to provide that person's care. The authorities are able to reduce their spending by up to a fifth by getting competitive bids and then choosing the cheapest available service.  They even boast about it.

This is an invitation (perverse incentive) to the providers to cut staffing and the other costs of care to win the bidding. The reports are here and also here. Even some in the USA are shocked and disgusted at the 'cattle markets'.  The US press reports that at least 12 UK councils are doing this.

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UK: Positive message - Targeting Dementia

As in Australia, there are mixed positive and negative messages coming from different sectors. The Prime Minister in the UK is mounting a massive project to research dementia and to train people to care for others with dementia. There is an overview from government on a press release "PM launches next phase of Britain’s fight against dementia" where there are links for those who want to follow this.

As in Australia, the current UK government has been pushing an aggressive privatisation campaign and been criticised for it.

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UK: The UK in crisis December 2015

Social Services in the UK system are under pressure. Government is not prepared to pay companies the money they need to be viable in the system that has been created. Care is collapsing and no one is coming up with answers. There is a growing volume of material analysing how the UK arrived at this impasse but not too many suggestions as to how to get out of it. While Australia is different in many ways we have, and still are, pursuing similar policies and there is much to learn.

Care home bankruptcy has become such a serious problem for local councils that the Quality Care Commission keeps a list of difficult to replace providers and facilities whose financial health it monitors. It warns the local authorities if those they use are at risk.

• Market Oversight of adult social care Care Quaity Commission web site

The UK’s largest nursing home chain, private equity owned Four Seasons is desperately shutting nursing homes in order to stay afloat. This must be because no one wants to buy them. This is happening in the face of an aged care bulge which like Australia the UK must meet.

• UK's biggest care home provider shuts loss-making homes The Guardian 24 Nov 2015

In the UK as in Australia it is so often only after whistle blowers notify authorities that problems are identified. While data collection is far superior to our quality agency oversight by periodic visits from government bodies like the CQC have not worked. This is why I argue that a local oversight presence is essential. Multiple problems were found in the home described below.

• Care home workers got elderly residents up for breakfast at 4am inspectors found The Mirror 6 Oct 2015

A politician who tried to help a constituent hit a brick wall when trying to have failures in care addressed. As he discovered ‘Of the 700 establishments most recently inspected, a staggering four in ten have been rated as either “requires improvement” or “inadequate”. The purpose of any regime of inspection and regulation must be to drive up standards. These figures alone suggest that the current system simply isn’t working’. ‘Despite a raft of reforms in recent years, the CQC is not fit for this particular purpose’.

• Something 'must be done now' to improve elderly care Western Morning News 8 Nov 2015

A review of the changes that have occurred in the provision of social services in the UK comments that “We have ended up with some pretty shocking services in social care because at the end of the day the market was about driving down prices, which it has very successfully done.”

• A quiet revolution: looking back at 20 years of social services reform : Adult and children’s services have faced many shakeups since the mid-90s – have they been improved? The Guardian 13 Oct 2015

An article in The Guardian looks at the way this system, in which publicly funded care has been contracted to the market, has failed because government can no longer, or for some other reason won’t, fund the profits the market need to make. I realise that an alternate system which is not as dependent on generating profits would also suffer but think it might have more latitude and cope better.

• Two-fifths of Britain's care homes below standard as budget cuts finally tell The Guardian 9 Nov 2015

An open letter to the new labour leader, Jeremy Corbett, examines the history and explores the failures in the provision of social services in the UK.

• Jeremy Corbyn, we need to talk about social care Peter Beresford The Guardian 12 Oct 2015

The article below explores what has gone wrong with social services in the UK. It seems that “funding issues now look to be threatening some of the central tenets of the (social services) act”. One critic believes that “the government has missed a golden opportunity not only to address an injustice but to make contact with the wider population and establish their care needs much earlier.

The comment that “one familiar ploy is to make the research fit the policy rather than vice-versa” should be very familiar to us in Australia as should concern that economic considerations are given disproportionate weight. One commentator indicated the “economic dimension is perfectly legitimate but it mustn’t trump the evidence from other sources.”

• From the Care Act to integration, is social care policy based on evidence? The guardian 27 Oct 2015
  
  

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NZ: Privatising Accreditation in New Zealand

Australia is now responding to our own problems with Accreditation by deciding to contract it out to the market.  New Zealand has a system of oversight contracted to the market.  It did not work either. 

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USA: Some background in care

Recent analysis of problems: In the 1990s I remember reading reviews claiming that problems in aged care had been ongoing for over 20 years in spite of inquiries and multiple efforts to deal with them. Now almost 20 years later reviews of aged care like that just done in California are using the same 20 year figure to say the same thing. California is currently going through the process all over again. Little seems to have changed.

In November 2014 The Sacromento Bee, a paper that has been writing and exposing problems in aged care for at least 20 years, published a three series in depth analysis of aged care in that state Unmasked Nursing Home. They examine the many measures of care and staffing that are available in the USA and describe the poor quality of care as well as the way staffing is deliberately reduced and money funnelled away.

The articles document the large variation between different providers. They track the complex and hidden ownership structure to show how ownership impacts on care. They illustrate what can happen in an aged care sector without effective customers - one dominated by corporate providers monitored by ineffective government agencies.

It seems that the largest and most commercially successful owner seems to be the worst when it comes to caring for its residents. Resident's families are suing.  Regulators are involved and one of its nursing homes is facing criminal charges.

• California's largest nursing home owner under fire from government regulators Sacramento Bee, 13 Jun 2015
• California’s largest nursing home owner sued Sacramento Bee, 12 Aug 2015
• Charges filed in south state nursing home death  Sacramento Bee, 28 Aug 2015

Extendicare is a Canadian company that does most of its business in the USA.  It was making headlines for all the wrong reasons in the late 1990s, usually for the record payments awarded by angry juries.  Fifteen years later its still doing it.

Government reports: The Senate Select Committee on Aging and Long Term Care in California released its report titled, A Shattered System: Reforming Long-Term Care in California on 20th January. I cannot pretend that I have done more than just read the executive summary and scan some of this large 211 page report.

It documents a fragmented organisational structure with a piecemeal and reactive approach to change. It calls for a long term plan and recommends legislative changes. It calls for better oversight and reporting, infrastructure for home care, delegation of tasks performed by nurses, investment to build infrastructure, engaging with federal authorities. It issues a call to action.

I studied the US aged system from the late 1990s to about 2004. Reading this report was groundhog day. I have seen this all before. The report fails to even look at the critical issues revolving round corporate ownership identified by the The Sacramento Bee newspaper and there is no thought of involving consumers.

Revealing, is that it does not make the complex ownership trail transparent, a key issue that the The Sacramento Bee highlighted.  Ownership was the key to what happened in nursing homes.  If they knew the real owner then potential residents would know the sort of nursing home their local one was likely to be. It is likely that the The Sacramento Bee knew what the senate eport would contain and why they did this investigation and published these reports. This complex paper trail has been the subject of criticism for many years.

The report acknowledges - but does not tell us about the real problems in the USA. It does illustrate the way they are handled using motherhood statements and proposing plans to show activity so keeping critics at bay. The way this is done is informative for us as our various reviews and reports over the last 17 years seem to have gone the same way as those in the USA.

Publicly available data: Unlike Australia, governments in the USA have not abolished the collection of objective information about care and staffing so although much is still missing there is considerably more information available.

The government run Nursing Home Compare web site allows the public to examine all of the data collected about any nursing home in the USA and there is similar information available for home care.

In addition, the entire data set is available to download so that researchers can evaluate the trends and relationships shown by the data and publich this. But it is the press, individuals and some academics, rather than government, that have collected information in the USA and analysed it.

The relationship between staffing and care (added Dec 2015): The USA has been more active in recording staffing levels and relating them to care than any other country. I am aware of articles starting in 1994 until recently - all saying the same things. Australia carefully avoids collecting this information and continues to make assertions and claims in the face of evidence.

As long ago as 2002 US authorities recommended a minimum of 4.5 hours of nursing care per resident per day because they had found that failures of care were likely below 4.1 hours and would be frequent below 2.9 hours. The extent to which US companies fail in meeting this is well known but with such a powerful lobby there has been little willingness to enforce it.  In Australia we simply don’t know what our staffing levels are and if we did we would not have any local data to measure it against.  Instead we continually have advertorials about innovations involving staff rotations that are claimed provide more for less staffing.  Until we actually collect data about failures in care and can prove it we should assume this is wishful thinking or commercial opportunism.

• Woefully inadequate staffing is at the root of patient neglect ST. LOUIS POST-DISPATCH 14 Oct 2002

Nursing home agreements remove the right to sue:  Nursing homes in the USA are pressuring residents to sign away their right to take court action for damages and to arbitrate instead. But by doing that, they give up their right to use the discovery process to procure documents, to subpoena witnesses for depositions, and to secure sworn testimony as to the facts of the case. They sign at a time of stress when they don’t understand.

Books about health and aged care: There have been some excellent analyses of health. The first by Dave Lindorff in 1992, which included aged care, was "Marketplace Medicine: The Rise of the For-Profit Hospital Chains". At the time it was considered to be biased by the medical profession and other reviewers were not persuaded by the arguments.

The second book by two award winning New York Times investigative journalists Bartlett and Steele 12 years later in 2004 was "Critical Condition: How Health Care in America Became Big Business & Bad Medicine". It was graphic in its examples and definite in its analysis describing a situation well beyond Lindorff's predictions. In a page describing the role that financial institutions advising big health care corporations played in health care that I wrote in 2004, I included several quotes and comments drawn from this book. The same marketplace approach and political solutions were applied to aged care. Academics and newspapers in the USA have written extensively about aged care.

All of this material and a succession of scandals have resulted in a trail of inquiries and recommendations, yet very little has changed. The USA has a number of issues inhibiting real change that we don't have. The first is that a free market is integral to The American Dream and any attempt to criticise it or tamper with it is seen as anti-American and lacks credibility. The public will complain and act - but they will not challenge this basic tenet of the American way of life. As a consequence, the solutions that these analysts propose have not really addressed the issues they have identified.

Politics and the marketplace in health and aged care: The problem Australia also has, but not to quite the same extent yet, is the close interdependence between politics and marketplace, with a revolving door and financial support binding the political process to marketplace concerns and economic ideology. Well thought out and motivated reports can make recommendations but if they do actually result in action they have been modified and massaged to accommodate to a multitude of powerful interests.

In my view, if the recommendations of the Californian senate report are acted on, they may make limited improvements but it is also likely to be simply another placebo to keep critics of problems in care at bay. A whole new study of data in a few years time will be needed to show that the problems are still there, but by then everyone will have moved on and a new groundhog day will start.

In 2004 I wrote a web page Politics, Markets, Health and Democracy  about the close relationship and interdependence of politics and markets in the USA and the relationship of this to health and aged care. Little has changed and I think it is still relevant 11 years later. There are lessons there.

(Added Dec 2015) Like the UK the USA is also facing a “looming crisis in family caregiving” and there is pressure to make this an election issue. Of the candidates only Hillary Clinton, who has had personal experience of the problems is taking any interest.  It is interesting that the limited legislative changes that have been made focus on supporting a community solution and are not looking to the market for help.

The corporate aged care lobby, like that in healthcare is enormously wealthy and powerful. It is very unlikely that any government could make effective changes even in the likely event that this became an election issue and that this brought a political party into power. Australia is no different and that is why we need to develop another strategy.  That is why ACC have opened the Solving Aged Care debate and why I am writing these web pages.

• Why some advocates are trying to push caregiving onto the 2016 presidential agenda The Washington Post 20 Oct 2015

A very confronting analysis: In the USA "grannycams" (hidden video cameras) are often used by families who are worried about what is happening to their families. There is a fairly recent very confronting video (be warned) on YouTube Fault Lines - Elderly Incorporated("Fault Lines investigates the business of elderly care, and what happens when corporations put profits ahead of care" - 20 Sep 2013).

Apart from some of the grannycam clips showing horrible abuse, there is nothing amateur about the video. It shows the same sort of video clips that contacts sent me in the late 1990s. It discussed the difficulty in detecting abuse and distinguishing it from illness and ageing by using external oversight and occasional visits as happens in Australia.

The video illustrates just how bad a strongly competitive and profit focussed aged care system dominated by large market listed chains and private equity can get. On "Part 5: Background to Community Aged care Hub" I describe how the conflicting paradigms (ways of thinking) in aged care cause people to become alienated - blunting their emotional responses and their ability to empathise and feel for others. They can respond by taking their resentment out on others or by amusing themselves by taunting them. Some of this is apparent on the video.

There is also a good discussion of why this is occurring - but the Americans are still talking about regulation and oversight. They are the best example of why neither is a solution. The proposed hub is intended to address this problem by having interested and committed people from the local community there regularly to see and question.

This video also exposes the dangers of a close link between politicians and the market showing how the industry has been protected. Our politicians also work closely with the providers rather than the community and the same situation exists here.

While the financial links keep politicians quiet, the truth is that politicians in the USA are now trapped because so much of the sector is controlled and operated by these chains that there is no one else to do it.

Pressure on them will only harm the residents and there would be chaos if they collapsed. This almost happened in 1999 when government cracked down on rorting. They had to help rescue the companies from bankruptcy because there was no one else to provide care.

This video is not nice viewing, but I think that anyone who is advocating and supporting the consolidation of our market using the sharemarket and private equity should be made to sit down and watch all of it. It's an in depth analysis and not a short clip. 

The proposed aged care hub attempts to address these issues by creating an intrinsic mechanism that fundamentally changes the pressures and social dynamics in the system.

Consumers organisations in the USA: The National Consumer Voice for Quality Long Tern Care is an organisation established in 1975 to pursue better care for the elderly.  The website describes the concerns in the USA and not surprisingly staffing, something that is systematically avoided by politicians in Australia, is one of their major concerns.

What has always interested me about the USA is that with all of the data they have, they carefully avoid criticisms of the marketplace or the impact of competitive pressures there.

I am sure that some of the leaders of these groups are aware of it.  The problem for them is that any criticism of the market in the USA is tantamount to heresy and would be attacked by the right. They would lose credibility in their own organisation. The competitive marketplace is considered to be the American Way.  To criticise, is an attack on the idea of being American and would undermine the organisations credibility, their membership and their ability to act effectively.  Compare the extract below with  UK community organisation's concerns about privatisation in previous sliders.

Wouldn't it be wonderful to know just how many hours of nursing care residents in Australia are getting?  4.1 hours is what experienced experts in the USA consider a safe level. When they get less than 4.1 hrs then problems become more likely.

The legal solution: Citizens in the USA simply do not have a credible solution to the aged care problem that the market has created. Anything other than a free market is un-American. They don’t see it as a system problem as much as a failure of the individuals.

The only solution they have is retribution and deterrence. They look to lawyers, the courts and massive penalties. They have been running law suits and getting massive penalties for at least 20 years. In most states politicians have blunted the deterance by capping the maximum damages that can be awarded. There has been some impact, but the costs of the lawsuits have pushed up the cost of insurance (which pays the settlements) and this has increased the costs for nursing homes putting more pressure on the system. Its a vicious circle.

I don’t have any difficulty in taking legal action when there have been failures - but on its own, it does not work effectively. It needs to be accompanied by a change in the system itself, one that turns off the pressures that drive the market to neglect the elderly.  The proposed aged care hub is intended to do this.

The YouTube video link below, is an advertisement for a law firm but it states the problem and illustrates the solutions offered.

• EXPOSING NURSING HOMES WHEN PROFITS are put OVER PEOPLE Moran Elder Law 18 Jun 2015

The providers response: To counter this, nursing homes have been forcing seniors to agree to arbitration in their nursing home contracts. Residents then have to arbitrate with a company friendly lawyer instead of, or before, they can take legal action. This is legal but the arbitration process deprives them of many of their rights and disadvantages them.

Another consumers group Caring Across Generations is trying to rally the community to press for change to the US system. One of the things they are doing is pressing to have this issue addressed.

• Editorial: Nursing homes take away right to sue The Des Moines Register Aug 19, 2015
• We need to be able to hold abusive nursing homes accountable Caring Across Generations 2013

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