Monetising your mum: The industrification of aged care

Even before the COVID-19 pandemic, in many parts of the world there have been considerable, ongoing concerns about care quality provision for older people, particularly for those in residential aged care facilities. People understand that something has been fundamentally corrupted when the care of our older citizens becomes ‘simply another commodity to be purchased, rather than an essential service that is their right’ (Davidson, 2018: 104). Depressingly, regular ‘scandal stories’ and public enquiries come and go, but nothing changes. A most egregious example is illustrated in the official report on the recent sudden closure and evacuation of the residents of an aged care facility in Australia. Among the many corporate outrages and derelictions of care uncovered, the report explicitly commends the home's care staff who ‘remained on site to support the residents amid the chaos despite being told they would not be paid or covered by insurance’, while roundly condemning the home's owners, managers and liquidators for their ‘deplorable lack of accountability (...) for the consequences of their actions’ (Commonwealth of Australia as represented by the Department of Health, 2019:4). The mistakes that ‘must never happen again’ reoccur and the ‘lessons that must be learned’ never are. We may never discover the true number of people who have died in residential care homes as a result of COVID-19 but reliable estimates suggest that it will be around half of all COVID-19 deaths worldwide (Reynolds, 2020; Comas-Herrera et al., 2020). The COVID-19 crisis has not created the crisis in aged care but rather it has ruthlessly exposed its every fatal flaw and failing. It is difficult to know where to begin to describe the utter bankruptcy of the current ‘aged care industry’ and their political backers. Whether it is the woeful lack of evidence-based clinical governance frameworks, or any coherent COVID-19 national planning that effectively protects residents, or the epic failures in care at almost every level. While aged care facilities are often advertised as homes and many have some superficial decor meant to resemble a private home, these are unabashed institutions and profit centres and the ethos within bears little resemblance to anything we would recognise as home (Molony, 2010) or to any place where we would feel ‘at home’ (de Veer & Kerkstra, 2001). Values such as dignity, autonomy, freedom of choice or person-centred care wither under a lexicon that reinforces capitalist and Taylorist ideologies exemplifying ‘assembly line’ (Daly & Szebehely, 2012:143) care and underpin most operations in this sector. Even outlining the catalogue of failures in human warehousing that exemplify today's ‘aged care industry’ is beyond the scope of this paper. Currently, in Australia, we have (yet another) enquiry underway— an entire Royal Commission forensically revealing all of these shortcomings (https://agedcare.royalcommission.gov.au/). The aged care industry has sunk beyond Ungerson's influential identification of ‘the commodification of care’ (Ungerson, 1997) to an even more bereft ‘corporatization of care’ (Farris & Marchetti, 2017:110), where ‘caregivers might not be the ones assessing the care needs; instead, they are only those implementing services designed by upper-level authorities, usually managers who might know very little about care’ (Farris & Marchetti, 2017:127). Here, however, we focus on the ‘linguistic Chernobyl’ (Solchanyk, 1992:xiii) that has seen every vestige of humanity and human connection expunged from the language of aged care, supplanted by the arid argot of managerialism, capitalism, industrialism and marketisation (Henderson & Willis, 2020) in the ‘new public management drive for productivity and effectiveness rather than quality and professionalism’ (Attrash-Najjar & Strier, 2020:35). Heidegger once observed that language does not simply describe, noting that; ‘Language is the house of being’ (Heidegger, 1977:193). If this truly is the new ‘house of being’ for our older relatives, friends and community members, it is fundamentally unfit for human habitation. The peak body for aged care providers in Australia is ‘The Aged Care Industry Association (ACIA)’ and therein lies the kernel of current aged care failings. This is a multibillion dollar (Lane, 2018), self-proclaimed ‘industry’ with both ‘not for profit’ (but not for loss) and ‘for profit’ sectors whose prime function is to monetise your mum. The stark economics of business profitability rarely change. To maximise profits and to benefit owners and shareholders (Bachelard, 2020a), which is the overriding aim, either income must be increased, via higher fees, charges or subsidies, or expenditure must be reduced, for example by minimising salaries and staffing costs, beginning with reducing professional nursing care, ‘economising’ on food and other essential services, or even both. As we write this, we have no doubt at all that an aged care warehouse, somewhere, will be having executive discussions regarding how they can ‘increase nutritional efficiencies’ in order to feed their human profit centres for even less than the reported $6.08 per day (Blumer, 2018). Within this business model, based on making money from older people, no profits will ever be ‘enough’ and the ‘industry’ will always plead poverty (Bachelard, 2020b). This is no character flaw in particular owners; it is the very essence of the model whereby owners and shareholders will always demand more profits and look for more ways to extract more money from every conceivable source. Egan (2018) reports one industry advisor anticipating that: ‘The funding model needs to be looked at [and] we need to allow providers to increase their revenue through the basic daily fee and have more clarity around what additional fees they can charge’,. (...) (Egan, 2018). The other much-needed change to revenue is with accommodation pricing, which is still too low and something providers should address through consumer education’. (Egan, 2018). Within such an industrial, neoliberal discourse, such claims cease to be breathtaking arrogance and entitlement and begin to seem like simply ‘business as usual’. Why should older people not pay increased fees to keep owners and shareholders satisfied? Why should every identifiable ‘service’ not carry ‘additional fees’ if this maximises revenue? Of course increased accommodation charges are ‘necessary’, and should any recalcitrant ‘consumers’ fail to appreciate this, then they are clearly at fault and require remedial ‘education’ from ‘providers’ to make them aware of the error of their ways. It is almost beyond parody. (We say ‘almost’ as Australia's ‘Sammy J has provided the best attempt here: https://youtu.be/ZzKNJBfvUlg). It is no surprise that Russell’s (2019) extensive research highlighted what her participants called the ‘obscene profits’ (Russell, 2019:ii) to be made from older people and their families and in addition to the $13 billion of federal subsidies (Butler & Davey, 2020) and ‘corporate welfare’ on offer, especially when this is combined with the aged care industry's concerted efforts at ‘tax minimisation’ (Tax Justice Network-Australia, 2018). When caring for and supporting older people becomes an ‘industry’ (Co-op, 2020), the rest of the marketplace language and ideology frames every imaginable dimension within this neoliberal mindset. As Rottenberg noted, such neoliberalism, ‘is also a form of reason that remakes everything into the image of the market’ (Rottenberg, 2018). Older people become ‘customers’ or ‘consumers’ and their families are ‘stakeholders’, exercising a mythical ‘consumer choice’ (Carder & Hernandez, 2004). Families and governments become conglomerate ‘cash generating units’ (West, 2019:S58). Efficiency becomes synonymous with reduced expenditure or increased income and has nothing whatsoever to do with ‘care’, ‘flexibility’ becomes the ability of management to order or mandate anything and have staff comply immediately, ‘reducing red tape’, means never having to establish any effective governance or transparency regarding costs, expenses, care failures or business processes (Connolly, 2020). Inevitably the industry foci on efficiency and profit generation translate into compromised care. As Henderson et al. (2018:355) found, ‘Employees working within government owned facilities reported levels of missed care that are significantly lower than privately owned facilities’ across six key areas. We have witnessed the wholesale ‘dismantling of nursing’ globally in acute care (Weinberg, 2003), but aged care is the undoubted zenith of this care vandalism. The aged care industry and their powerful backers and lobbyists have been remarkably successful in using the positive connotations of qualified nursing for their own ends, while fervently avoiding any of its standards, practices, ratios, salaries or responsibilities (Jackson & Raftos, 1997). Aged care staffing is now a byword for the exploitation of many of society's most vulnerable people, such as new migrants (Fine & Mitchell, 2007; van Hooren, 2012), or new mothers (Palmer & Eveline, 2012) who have few other options, and who are desperate for any employment. Often these ‘gendered and ethnicised’ (Schwiter et al., 2018:386) staff are working several jobs in precarious, casualised and unsafe environments (Keane, 2020). Even 10 years ago, aged care was notorious as ‘an industry that would employ anybody’ (De Bellis, 2010:101). The Australian Bureau of Statistics has noted that since the last census of 2012 the number of immigrant care workers in residential aged care has risen from 79% to 91% with the majority being unregulated care workers (Willis et al., 2018). It is a measure of this carefully engineered debacle that legislation ‘to ensure at least one registered nurse is on duty at all times in high-care nursing homes’ is trumpeted as some kind of care quality achievement (Anon, 2017). Residential aged care staff might be referred to as ‘nurses’ in day-to-day language (De Bellis, 2010), leading residents and their families to believe they are getting what they imagine they are paying for—expert nursing care. This myth of available expertise is carefully reinforced through the deliberate misappropriation of nursing iconography (Jackson & Raftos, 1997). Google ‘aged care staff stock photos’, exactly as the industry does, and be prepared to adorn your corporate brochures or company website from the copious pages of young, smiling, overwhelmingly white, young women who will appear wearing the proverbial white or blue uniforms or scrubs, donning items such as corporate badges, and strategically placed stethoscopes, and with an arm caringly draped across the shoulders of a smiling older person. The unpalatable reality is that today's aged care workforce is not ‘uncaring’, but as ‘untrained, uneducated and unskilled non-nurses’ (De Bellis, 2010: p.108), they are as far from highly qualified, expert, aged care nurses as it is possible to be. Since deregulation and ‘marketisation’ of the ‘industry’ throughout the 1980 s and 1990 s (Davidson, 2018), the race to the educational and staffing bottom has been relentless (Willis et al., 2016). Where once aged care nursing was a specialist area deserving of a postgraduate qualification of equal status and merit to Intensive Care, Paediatric or Mental Health Nursing, we now see entire facilities staffed by the absolute minimum level of qualification and expertise. For nearly a generation, nurses fought to raise the profile and status of aged care to reflect its human and social importance and to rid society of the notion that this was just ‘washing, feeding & walking’ that anyone could do. It is beyond heartbreaking now to see that the, ‘We have joined the BBC – British Bottom Cleaners’ (McGregor, 2007) characterisation of aged care and the contempt in which such work is held (Dwyer, 2020) is back with a vengeance. In any ‘care home’, it is not unusual at all to find one qualified nurse on duty who is supposedly ‘supervising’ all of the unqualified or barely Certificate III accredited ‘pairs of hands’ providing all of the actual care to a ‘home’ full of older people with a barely imaginable array of complex health and social care needs and other comorbidities. Despite the best efforts of many wonderful aged care nurses who understand fully that caring for older people demands the best skills that nursing can offer (McGilton et al., 2020), there can be no surprise that the debasement of aged care has led to such nursing being thought by many as the lowest rung of professional nursing (Neeland, 2018). Meanwhile, every care home mandarin will claim endlessly that none of their downsizing, cost-cutting, outsourcing, dumbing down or efficiency measures will have any negative impact on care quality. For good measure, they will be sure to host high profile award ceremonies where the industry can bask in its own PR echo chamber of ‘innovation’ and ‘excellence’. The industry's attempts to control the language and discourse of aged care will only increase, as their survival and profits depend upon this. The latest industry move is a new peak of cynicism, even for them. Apparently what the aged care sector requires is not more qualified nurses and better health care but more spin doctors. In order to ‘change the conversation’ about aged care, the biggest players have banded together to hire a top Public Relations firm to help ‘win the hearts and minds of middle Australia’ (Brooks & Kruger, 2020). Be assured that this ‘changed conversation’ will not mention anything about obscene profits, depleted RN staffing ratios, nonexistent funding transparency or the enforced lack of publicly available care quality data. Instead, the ‘conversation’ that the industry wants to control will be full of exciting young entrepreneurs ‘disrupting’ a tired old industry, ‘focusing on the positive stories of aged care’, needing to further ‘cut red tape and bureaucracy’, showing how the aged care industry is providing more ‘choice’ for older people, claiming the need for staff with the ‘broadest range of skills available’ in care settings, explaining how they ‘work closely with all stakeholders’ and ‘educating us’ to show just ‘how open and collaborative’ they are, promising ‘transformation’ using ‘tomorrow's technologies’ such as the ‘robots who care’ (Sparrow & Sparrow, 2006) and most important of all, spruiking the ‘desperate need to increase government funding’ for this ‘vital industry that is here to care for every one of us when we need it’. The industry will relentlessly assure us that ‘old age is not an illness’ and does not require ‘medical model’ care (Connolly, 2020), thus legitimising the erasure of nurses and required health care from their system. ‘Happy ageing’, ‘healthy ageing’, ‘positive ageing’ and their imagery of silver-haired kayakers, dancers, cyclists, surfers and more will be the marketing tools used to convince us that older people will never need expert, professional health care, only occasional kindly support from the ‘customer service consultants’. It will be a public relations onslaught of emetic proportion. If Heidegger was correct in his observation that, ‘Language is the house of being’, (Heidegger, 1977:193), then the ‘aged care industry’ is a slum landlord presiding over a bereft terminology and a factory model fit only for demolition. It is a mistake, however, to assume that the aged care industry is failing or in crisis. On the contrary, it is making huge profits, it squeezes as much money from older people, their families and governments as it possibly can, it has cut service costs to the bone in every area, it has opposed every vestige of genuine transparency and accountability, it has consistently placed finances above people and it has ensured that the language of money and the marketplace dominates aged care discourse. As Peter Rozen, QC, told the Royal Commission into Aged Care Quality and Safety, ‘It is the system operating as it was designed to operate. We should not be surprised at the results’ (Morton, 2020). Just as the catastrophic outcomes of this failed aged care system and how it was impacted on by the COVID crisis are evaluated by the ‘industry experts’, so too will it be evaluated by its supposed ‘consumers’. Older people today and in particular the nearly 1 billion baby boomers globally are a savvy, educated and frugal population worth more than 3 trillion dollars worth of income to the economy. Their concerns are how an aged care system will look to them and how it will work for rather than how much profit it will for owners and of or PR are to or families to the standards, and exploitation that have the system over the last few Older people demand more from aged care than a where they will be and a system of person-centred care, an of their care of connection to and friends and a in governance regarding the daily operations of the of care’ et al., not a profit If this or of government and then so be Older people and their families of available in care and to be sure that providers and their staff are and to and needs that will across full from support to of care. A nursing home or nothing will no be an Aged care providers of the will need to begin with an of clinical This must to all to and governments that there is a high level of and service into every of every governance must the of and from all in providing and operating a Within this it should be to all and especially to any residents and their what levels of care and accommodation are what there are to from when change is and exactly what costs will be To aged care providers have of such of and community quality of care and It is to this particular in aged care. It is now to an aged care system that will profit all of rather than the few and that will and older people, rather than and