December 11, 2019

Issues and policies

Is elder abuse avoidable?

By Russell Marks
Image of a woman’s hands

Photograph by Sabine van Erp / Pixabay

Our current aged-care system makes it difficult to deliver care in its truest sense

“A shocking tale of neglect” is how the aged care royal commissioners Richard Tracey and Lynell Briggs opened their interim report, released in late October. The commission is in Canberra this week learning about interfaces between aged care and the health system.

Neglect is an apt title for that interim report. The picture it paints is of a sector where elderly people are regularly sedated and physically restrained without consent or authorisation; where staffing ratios are inadequate; where too many staff are underpaid, overworked, under-trained and unsupported. 

But it’s not as if we – or at least those responsible for aged care – didn’t know what was going on. The public nursing home scandals that broke during the late 1970s led to the first public reviews and inquiries. There have now been dozens. By the late 1980s concerns about the growing institutionalisation of the elderly led to a series of policy reforms that sought to prioritise – all at the same time – budget sustainability, quality of care and choice for its elderly “consumers”. That proved too expensive. Neoliberal ideas underpinned the Howard government’s Aged Care Act 1997, whose “lighter-touch” approach to accreditation was designed to encourage more aged-care providers – including profit-seekers – to enter the sector, unburdened by red tape. Perhaps predictably, that approach also attracted profiteers. By 2018, when Canberra controlled every aspect of the increasingly expensive aged-care system, the federal health department was still aiming for an approach that was “more consumer-driven, market-based and less regulated”.

But very little had changed for too many people who needed care during their retired and twilight years. Clients and their families continued to complain about their lack of agency, the poor quality of care being provided by under-resourced staff, and the impossibility of getting increasingly corporate managements to listen.

Providers and their peak associations continue to deny allegations of abuse and neglect, and resist meaningful reform. Meanwhile, for-profit agencies return enormous windfalls to their shareholders. Bupa, Opal and Allity are just three of the industry giants who together turned profits of $1.7 billion last financial year.

No doubt the royal commission will make worthy recommendations about the need to increase funding and reform funding models; to improve staff training, conditions, support (and no doubt incomes); and to encourage greater accountability and, ultimately, better care.

One question that may not be asked, however, is whether it’s even possible for institutions in this system to provide “care” of the kind that people need?

Operating at their best, our institutions – aged-care providers, but also hospitals, schools and childcare facilities – can be good at providing the structural basics of care: shelter, food, even clinical services. Australia’s economic capacity to provide these basics, however, must be seriously questioned. The future costs of aged care to the federal budget must increase. More of us are living longer – not only do our “productive” years (during which we make contributions to general taxation revenue) assume smaller proportions of our lives, but the public funds spent on our health care grow as we age. Yet governments continue to slash tax rates for both companies and individuals. Parliament’s July “gift” of $158 billion over the next decade to the middle classes – in the form of unprecedented structural tax cuts – was stolen from their future aged selves.

The aged-care sector is not the only one in which we can find profiteering corporations and corporate not-for-profits running institutions in which vulnerable clients are abused, neglected and occasionally killed. In these respects, the aged-care sector looks disturbingly similar to youth residential care. Like their elderly counterparts, teenagers who can’t live at home or anywhere else are often ordered to make their homes with other kids in the same situation in houses staffed by underpaid, often underqualified and definitely under-supported youth workers. Sometimes kids in these places get the basics – a roof over their heads and enough to eat.

What they rarely get, though, is the kind of care that other children take for granted: the care, and love, of a “good enough” parent. Inquiry after inquiry into the neglect and abuse that is often rife at youth residential “care” homes finds child protection departments – who either run them directly or fund organisations that do – emotionally, psychologically and developmentally incompetent. I’ve known departments to think nothing – or not nearly enough – of removing 14-year-old children from their homes, transporting them hundreds of kilometres away to places entirely foreign to them, justifying the displacement by indicating the food and shelter the child is now receiving, and then blaming the children for behaving badly in response.

Recent calls for the professionalisation of foster care, for instance, miss the point in this respect. Can “professional” care ever deliver the attention, kindness, support and, indeed, love that is required to meet a child’s emotional needs? And can professionalised aged care ever really take the place of a middle-aged son, daughter, or other relative?

These questions are mostly moot, I suspect. The economic system we’ve built – and in which our aged-care system exists – is structured around nuclear household units and peak earning capacity in middle age (which is often just the point at which our aged parents require the most care). Even when there are family members willing in theory to provide the necessary care, they’re often economically unable to – and most don’t have the necessary skills. Residential facilities for the old and the young follow the principle Marx first identified in factories, where both production of goods and surveillance of workers was more efficient: these places make economic sense, because they group people together.

But they also group their disadvantages, sever accountabilities and slip easily into dens of despair. Can that be prevented?

There may be clues in other institutions. Schools, for instance, are much more open and accountable (at least on questions of abuse and neglect) than they were for earlier generations, and primary school teachers in particular are good at taking most children’s emotional and developmental needs seriously. But most schools aren’t residential, and those that are – boarding schools – are hardly immune from abuse and scandal. It’s probably no surprise that maltreatment flourishes most in places where people live: prisons, youth detention centres, youth residential homes and aged-care facilities.

Institutions can be pretty good at the provision of clinical care. But when it comes to meeting emotional, social and psychological needs, they’re generally pretty bad. How do we build, and pay for, systems that promote not just bare survival but also meet our fundamental needs as human beings? This will be the ultimate question for the royal commission, and for all future governments.

Russell Marks

Russell Marks is a lawyer and an adjunct research fellow at La Trobe University. He is the author of Crime and Punishment: Offenders and Victims in a Broken Justice System (Black Inc., 2015). 

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