Consequences of government aged care policy:
Research at University of Technology Sydney
This slider section looks at research into developments in aged care, related to government policy.
Richard Baldwin, Lyn Chenoweth and Marie dela Rama, a group of researchers at the University of Technology have warned of a maldistribution of services and a lack of choice for many because of the government's policies in aged care. This could also have consequences for the care they receive and their quality of life.
This is the second paper they have written about the increasing number of for-profit operators (whom they have found perform less well than the not-for-profit operators). As in their previous paper they are urging a vigorous debate in the community about the direction that aged care is currently taking. A review of the article is on Australian Ageing Agenda here.
The original article is titled: Residential Aged Care Policy in Australia - Are We Learning from Evidence? in the Australian Journal of Public Administration. Their earlier article Quality failures in residential aged care in Australia evaluates the performance of aged care providers in Australia. Their public comments about this are in a report "For-profit providers more likely to be sanctioned" on the Australian Aged Care Agenda website.
- - - - it (Australian Government) appears to be indifferent to other structural factors.- - - -
Neither the previous, nor the current, Australian Government has indicated a preference on the future mix of service providers, the growth of large providers, or the size of facilities. This suggests that policy makers, even in the light of the available evidence, have enabled these trends to continue through their silence, or are at least comfortable with the direction in which the industry is headed.
- - - - there had been little community debate on what is preferred. There is clearly a need to obtain more evidence on the impact structural change will have on the quality of care and the performance of the industry. There is also a clear need for wider community debate on the future shape of the residential aged care industry in Australia.
Source: Residential Aged Care Policy in Australia - Are We Learning from Evidence? - Baldwin R et al Australian Journal of Public Administration, vol. 00, no. 0, pp. 1-14
In an excellent opinion piece on pages 20 and 21 of the May-June edition of Australian Ageing Agenda, Richard Baldwin who did this work, again emphasises the lack of information about the quality of aged care in Australia and the absence of any plans to really collect this information.
In this paper, he looks at the way the Australian government's policy is likely to play out with more large for-profit operators, larger facilities, greater focus on profitability, lower numbers and skills of staff, greater use of agency staff and greater competition.
He looks at the available information from studies in Australia and internationally that indicate that each of these are associated with poorer quality of care. He indicates that in Australia the benefits of competition are assumed to be self-evident, but research indicates that greater competition may reduce prices but at the expense of quality which is compromised.
For instance, in a paper published in 2009, Vikram Comondore and colleagues reviewed 82 studies of residential aged care services and found only three favoured for-profit service providers, while 40 studies favoured not-for-profit services – in relation to more and higher quality staffing and lower pressure ulcer prevalence.
Rather than providing evidence to support the contention that as competition increases so too does quality, the research has in fact found the opposite; studies in 2004 and 2009 found evidence showing that as competition increased, quality overall decreased.
Source: Unfolding changes warrant greater scrutiny by Richard Baldwin in Australian Ageing Agenda May-June 2015 pages 20-21
The emphasis of the paper is on the need to collect sufficient information to monitor the impact of policy as it is introduced, something that is not being done and that has not been incorporated into the proposed changes. He repeats this message in another article below.
Industry observers have suggested that the for-profit sector is better placed than the not-for-profit sector to take advantage of the current and expected future market based reforms. Hence for-profit providers can be expected to continue to expand as a proportion of the sector.
This distribution of services (between rural and metropolitan) suggests insufficient competition across large parts of Australia to enable a market based system to operate effectively. Consequently, we may see the emergence of a two tiered system in Australian aged care based on economic and geographical factors
USA studies have found that homes owned by the largest aged care providers (those with 10,000 beds or more) tended to have higher failure rates of regulatory compliance per home and these violations tended to be more serious than those of smaller organisations. Larger organisations have also been found to focus on profit maximisation, rather than on quality outcomes, and to provide lower nursing staff to resident ratios than do smaller providers
This debate should be around the community’s acceptance of the trade-offs to be made between choice, cost and quality.
There is also a need for wider community debate on whether the Australian community is comfortable with policies that will allow, and even encourage, for-profit operators to emerge as the dominant type of aged care providers.
Source: The Future of Aged Care in Australia: A Call for Evidence Based Policy - The Policy Space, 22 Sep 2015
Baldwin is stressing the consequences of current aged care policy. These are:
- an inequitable system based on location
- an aged care system consisting of ever larger aged care corporations and larger nursing homes. Evidence clearly shows that both are strongly associated with poorer staffing and worse care. In other words government policy is putting a strong negative pressure on care and this is not in the interests of Australia or of its elderly citizens.
Very similar information was already available in 1997 when the current aged care system was set up. I was researching health and aged care at the time and personally sent politicians of all parties a large amount of information and summarised the evidence for them in a covering note. None of that was acknowledged or debated publicly. Instead, both parties scored points by focussing on hip pocket issues like selling the family home. The aged care system we have is a consequence of this and as Baldwin has shown it is likely to get worse - much worse if that is possible.
The Policy Space is an independent political forum. In the article quoted above and also linked to below, Richard Baldwin explores these issues again and asserts “These findings suggests that changes to the structure of the aged care industry could have an impact on future quality and therefore should be the topic of wide public debate.” That is what this web site is attempting.
A study from the USA in late 2014 adds to Baldwins arguments. It showed that private equity owned businesses performed even more poorly than the big for-profit aged care chains, and the longer they owned the business the worse the care became..
(Added December 2015)
Vulnerability: Carol Bennett the new CEO of Alzheimers Australia is being much more outspoken than her predecessors. She is not only being outspoken about the absence of data in aged care but is also stressing the vulnerability of consumers and the limits of markets in achieving social objectives - giving consumers choice did not mean that they would get it. There was concern about “how a more market-based system would operate in practice”.
She uses their success in health care to advocate for Quality Indicators, but that is not a valid reason for claiming that they will be effective in aged care if introduced in the same way. Doctors have ethical and professional reasons for supporting QI’s and protecting them. In aged care markets, QI’s have been rorted. There are strong pressures to game the system. Big companies sometimes accuse their competitors of doing so. Nursing homes do not have a powerful group ready and able to control corporate market excesses. Hospitals do.
Bennett comes from a marketplace background and I think she should start thinking about community solutions because the solutions she advocates have not been reliable. A community solutions has a greater chance of success.
Absence of data: In a radio interview advocating a national debate about the state of aged care as the sector moved from a welfare style system to one that is market driven, both Richard Baldwin and Carol Bennett, the new CEO of Alzheimers Australia were interviewed. Bennet indicated that quality of care was one of the biggest gaping holes because we don’t have “a single measure of quality” and without accurate data about care you cannot have choices. She could not understand why this was so. Baldwin supported her comments. Lynda Saltarelli from aged care added to that by stressing the importance of information about staffing because deficiencies in staffing were causing failures in care. Deregulation by government would see a greater role played by for-profit corporations which Bladwin had shown more often understaffed.
The political response to evidence: Politics has become the art of successfully selling and applying ideology. In order to accomplish this inconvenient evidence, reason and common sense are relegated to the depths of conscientiousness. A number of psychological strategies are used to accomplish this.
Mark Butler, the recent federal labour minister for ageing was the person who initiated the Productivity Commission and followed on to develop the 2014 marketplace “reforms” euphemistically called the “Living longer living better” reforms
Butler has written a book in which he is optimistic about the benefits of our longevity. It is interesting to see him talking about consumers who “have cognitive impairment when they're making these decisions (about choices)” in the same sentence as he advocates the importance of ensuring “that older people have access to good consumer information”. The absence of information was somethimg he ignored while he was in power and could have done something about. He fails to tell us how the cognitively impaired will comprehend and use that information. This is the weakness in his argument, the one he chose to ignore when he sold these aged care “reforms” to the public.
This is a good example of “compartmentalisation” a psychological process used by those who maintain an ideology in the face of evidence. I write more about this and its contribution to the paradigm paralysis in our political system on my own blog.
What are the prospects of our new liberal government paying any attention to the evidence accumulated by Baldwin and the logic of Bennett?. They will only do so when forced to do so by a public that engages with the issues?
The shift from a welfare service to a market: Nowhere is the shift in focus and thinking from citizens and the actual care they need to the market - succeeding and surviving in it - more apparent than in the papers given to the ACSA forum in Victoria on 30th October.
The bulk of the papers were given by large business groups including accounting firms, business consulting and support firms specialising in market strategies, marketing firms specialising in creating a brand, in marketing and in selling aged care products. The few government and not-for-profit providers who spoke did not deviate from the market themes of takeovers, finances, costs, profits, market strategies, viability, selling services to consumers etc.
A table shown by Ansell Strategic, who specialise in “strategies for the leaders of aged care organisations”, showed that only 3 of the top 10 (largest) aged care providers are now not-for-profit. This illustrates how much the sector has changed.
There is no doubt about the primary concerns of the industry, and where the resources, energies and strategies of the aged care providers are focussed and where all the extra money we believed was going to care is going. These businesses making presentations are all offering market services to the industry and this was an opportunity for them to display their wares. Their services will not come cheap.
We citizens thought that the extra money devoted to the Living longer living better package was to improve our care. We wondered why the big corporations' reports to shareholders showed that they were making more money by treating sicker residents yet spending less on staff. We wondered why consumers were complaining about the large sums taken in fees by the providers from the packages of money allocated to them under Consumer Directed Care (CDC). They found themselves paying more out of their pockets yet getting less care than they had under the old system. Now we realise its all about efficiency - marketplace efficiency - the goal of our government!
We believe that we need to design a system that provides care and not one that has an insatiable appetite for easy money and needs to have ever more money thrown to it to keep it alive. We should stop throwing money at a failed system and go back to the drawing board to design one that uses our money to provide care.
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