The onion juice sometimes obscures the inconvenient, or unspeakable truths
One of the early sections of the report of the royal commission into aged care is called “Inconvenient truths.” It’s a section which fleshes out some of the conditions which have produced an aged care sector where there are shocking levels of neglect of patients – a “cruel and harmful system” which is often “unkind and uncaring”, providing poor treatment and health care management, “dreadful food”, assaults, and abuse of physical and sedative restraints so as to make patients drowsy and compliant.
It’s a shocking story, calling for generous applications of the onion by politicians who have known the truth all along. The Morrison government moved quickly to establish the inquiry to take the heat from a Four Corners report on aged care facilities – thus giving the impression that it had been astonished by what was foreshadowed but was now moving swiftly to do something. But no Australian with relatives in residential care could claim to have been surprised.
That is not to say that all people in the system undergo the systemic abuse reported to the inquiry. But abuse, substandard care, and neglect of patients is so widespread, so frequently discussed, and so much covered in the news that ignorance could never be a defence. For relatives, moreover knowledge is often suffused with guilt at a feeling they have abandoned the inmates.
That said, the royal commission dances around a serious inconvenient fact, and in a way that may undermine its moral message.
The poor quality of aged care is not fundamentally a problem of brutalised aged care workers consciously maltreating patients. It is, rather, a function of the fact that a good deal of the industry is operated by private sector providers making very large profits out of the public money subsidising aged care.
So as to maximise these profits, they have long been squeezing staffing levels, reducing the quantity and quality of goods and services provided to residents, and, all too often drugging them so that they are neither a bother nor demand anything. They often leave immobile and incontinent residents sitting or lying in faeces and urine for inordinate periods. A good deal of the neglect and abuse – sometimes physical abuse – is a direct consequence of conscious efforts by managements to squeeze costs by putting profit before people.
At least until the royal commission, one has to take it that many of the providers factored into their profit calculations a certain amount of ”noise” – protests from residents, protests and occasional resort to the media by relatives shocked at the neglect of residents, and the continued complaints from nurses and other aged care workers about understaffing, incapacity to properly attend to patients’ needs, and the long term distortion to a system focused primarily on turning subsidies into spare cash for the operators. One gets the impression that more money was spent on public relations and glossy brochures than food.
The big players – operations such as BUPA, Opal, Allity, Regis, Estia and Japara – seem to average a return of about 10 per cent on their income. These collectively command about 10 per cent of the total aged care market – or about 20 per cent of private sector operations. Not-for-profits – including church-run organisations – take up about half the total market but the private sector role is increasing faster with more than a thousand providers.
Typically about 70 to 80 per cent of the revenue of such operations comes directly from farming government subsidies for aged care – generally the remainder comes from one form or another of contributions gathered from residents and their families.
But it is hard to make good estimates of just how profitable the system is. According to a report several years ago from the Tax Justice Network, many of the corporate structures are complex, with frequent and large related-party transactions (for rent, management and other services) capable of hiding profits from the taxman.
“It is difficult to get a detailed and complete picture of the full extent to which these heavily subsidised aged care companies are avoiding paying as much tax as they should, because Australian law is not currently strong enough to ensure that their financial records and accounting practices are publicly available and fully transparent,’’ the report, which was commissioned by the nursing lobby, said.
“The six largest firms received $2.17 billion in annual taxpayer-funded subsidies, which provided after tax profits of $210 million. The actual operating profits were much higher. These providers only paid around $150 million in tax in 2015-16.”
The report said that companies that receive millions in taxpayer-funded subsidies from government instrumentalities should be required by law to meet higher standards of transparency in financial reports and be publicly accountable.
Some of these companies were among those savaged by the commission. One, BUPA, has recently settled a tax claim.
Institutions operated by the not-for-profit sector, providing about 50 per cent of the beds available, were also heavily criticised. Their bad performance cannot be blamed directly on the profit motive, even if, sometimes a want of rapaciousness has inhibited the impulse to expand so as to get a bigger slice of the pie. Smaller operations miss out on some economies of scale. This can, alas, lead to a similar revenue-hungry and cost-cutting mentality owing more to concern about the bottom line than a concern for the proper care and dignity of residents.
And, when the Productivity Commission was examining the industry less than a decade ago, too many of them jumped on the bandwagon of the for-profits in a claim that the big drag on inhibition and efficiency in the industry was over-regulation. That, of course, is always music to the ears of the productivity commission, and its report recommending massive deregulation was issued around about the time that Josh Frydenberg was beginning his ministerial career by pretending to start bonfires of unnecessary, tedious and inefficient regulations.
It was like this too with the ideological mania to deregulate the finance industry. Ministers, it seems, just did not appreciate that their mates and cronies (generous party donors too) were in the game to make a quid, not to be disinterested altruists who could be relied upon to do the right and decent thing.
After the Hayne commission, we all know better, of course, even if Scott Morrison, then Treasurer, had to be dragged kicking and screaming into the idea of the need for such an inquiry. With the aged care in residential homes, regulation has already returned, and, no doubt, will become even tougher after the commission’s interim report. The impetus may be the stronger given that people experience more visceral disgust at deliberate physical and psychic cruelties to grandparents than at the rapaciousness of financial consultants and bankers in charging for services not rendered, sometimes even for dead people.
We will be very soon hearing similar stories about violence, abuse, neglect, and exploitation as the disability royal commission cranks up, just in time to fill the temporary void caused by the gap between the aged care industry interim and final report. We already know, more or less, what the parade of witnesses will say thanks to the advocacy for the commission, led by Senator Jordan Steele-John, of the Greens.
Indeed it might do even better in the publicity stakes. No one could have accused the (late) Richard Tracey, QC, or former Australian Public Service Commissioner, Lynelle Briggs, or, for that matter Ken Hayne, of being natural- born publicity hounds, even if the subject matter to which they have turned their attention proved to be of compelling public interest.
But Ron Sackville, chairman of the disability commission, and of an age almost fitting him to be president of the United States, rather adores the limelight and his own dignity. There is more than enough potential for friction, fraction and a good deal of smoke and fire.
I wonder sometimes whether we line up such inquiries as a form of serial public entertainment – a distraction – albeit with tragedy – from other matters government is keen to conceal. That may be why they are often reluctant to expand terms of reference too wide lest one day we run out of assaults on human dignity to deplore.
Last year we had sexual abuse of children in institutional care, including at schools, orphanages and by religious groups. We, or at least Julia Gillard, consciously decided not to include the physical abuse of children in the terms of reference, but had she done so, there would have been extra harrowing chapters of ruined and wrecked lives, and crimes calling out for justice. Perhaps we can have such an inquiry next. It wouldn’t hurt Morrison – he can blame state administrators.
Morrison has delivered a handsome and heartfelt apology to survivors and victims of child sexual abuse.
Before that we have had, after long and often harrowing inquiries, apologies to the Aboriginal stolen generation, to surplus British children exported after the war to Australia, and to the victims (mothers and children) of the forced adoption policies that operated, more or less officially, until the mid-1970s.
These three have something interesting in common. Once we heard the stories, it seemed immediately clear that what had happened was wrong. There were now social workers to say so. And judges and lawyers, and clergymen and women, as well as bureaucrats from state welfare systems and any number of politicians. Most expressed shock at what they heard. They are now unanimous.
Yet their counterparts, say 60 years ago, were also unanimous in supporting the policies of the day. Stealing Aboriginal children, importing supposedly orphaned British, or cajoling single women to surrender babies was government policy. It was implemented with zeal and righteousness by the politicians, bureaucrats, judges, lawyers, religious and moral leaders, and social workers. Few at the time expressed any qualms at all.
The modern generation believes, by almost fundamental instinct, that they were gravely wrong. We ought to apologise, compensate and make sure it can’t happen again. I sometimes wonder how it is that we can be so sure that we now know better. I say that without a scintilla of support for the old ways.
Despite Rudd’s apology Aboriginal children are now being removed from their parents in greater numbers and proportions than ever. It is no longer, of course, just because they are Aboriginal; on paper, as they are sausaged past the highly compliant magistrates and judges, it is apparently because they are at grave risk among their own family. No doubt many are or were. Yet the record of the stolen generation, as much as of abuse in institutions shows that only rarely could the social workers, or the judges, be sure that they were delivering the children to a better, or a safer place, let alone to a place which respected their dignity and their rights. More often it was from a bad place to one worse.
In any event, Aboriginal children were only a subset – perhaps 20 per cent — of young Australians seized for their own good and put in welfare institutions during the first two-thirds of the 20th century. The goody-goodies responsible were apparently blissfully unaware that there they would suffer systemic sexual, physical and emotional abuse – long term injuries ending up costing society at large many times the cost of providing “welfare” on the cheap.
A good many Australians have no memory or understanding of the blight that fear of, or the fact of, welfare seizure of kids cast over working class and underclass communities 50 years ago. No doubt the practitioners were well-intentioned, even righteous. Few of their targets understand that even now. Nor, at any rate, is meaning well an excuse.
So we could have a royal commission, if we wanted, into such victims. We could also have an inquiry into systems of juvenile detention in various parts of Australia, and their role and effect in rehabilitating children of whom the police, the welfare system and the judiciary have despaired. Australia is still mostly medieval in such matters. I very much doubt that the ACT system would be found to be a shining beacon of effective and just management of the problem any more than our adult jail is any sort of model for anyone else to follow.
Indeed, we could have a national inquiry into adult prisons given that Australia-wide, the judiciary is now sending young adult Australians to jail at a rate about double that of two decades ago. This is even as the minister for home affairs, Peter Dutton, an ex-cop, predictably complains of lefty pinko softy judges, too inclined to administer only taps on the wrists. During that period, the crime rate has fallen substantially, and not because the criminal class is largely behind bars.
One day, of course, we will have a royal commission into our treatment and respect for human rights during the incarceration of asylum seekers in faraway concentration camps. The longer it is deferred, the more monstrous and disgusting all of the players – Labor and Liberal, and the bureaucrats – will seem to the next generation.
But that inquiry will presumably be after a searching study of how robo-debt wrecked human lives, human rights and common dignity and made monsters of welfare administrators.
Royal commissions and inquiries serve a number of purposes. One – often under-rated — is to serve as a theatre at which people affected by the matters in question can tell their story. Victims will have ideas about better policies, or why past policies were so wrong. Being listened to with respect is as important as being heard. For many the mere giving of witness in an understanding, accepting and dignified environment is by itself liberating. Most recent inquiries have been exemplary on this.
In many cases, an inquiry serves also to establish what went wrong. That’s a good reason to have at least some legal fact-finding ability and some experience with bureaucratic government on board, even if, in my opinion, the best inquiries are often conducted by the laity rather than the experts.
The third function is to advise on future policy, often including tricky questions such as compensation, the punishment of the guilty and the prevention of further problems. There are a number of difficulties with this. Royal commissioners, particularly those with healthy egos (and which ones do not have them?) are not always well suited as appropriators of public money or as rationers of public resources. They may prefer to get the plaudits for their kindness with public money. We might want generous compensation, say to abused children, but what are we to have less of as a result? If there are to be special rights for A, what of B, or C?
Royal commissions cost lots of money – annually often hundreds of millions. I wonder, sometimes, whether we ought to have some standing official – accompanied by the equivalent of counsel assisting – to conduct regular hearings at which people complaining of suffering as a result of past or present systemic failures of policy and practice could be heard. If it draws attention, there might be other quicker and cheaper ways, also public and accountable, for reviewing policy and practice.
That has nothing to do, of course, with the inquiries we ought to be having – ones able to be avoided if there is a steady diet of harrowing accounts of human misery. Like inquiries into the police. Or into public corruption and the effectiveness of existing watchdog agencies. Or into water administration in Australia. Or management of the Great Barrier Reef. Or as some are asking into horse racing. And underpayment by employers.
Do the silent people want such things?. Or do their loud representatives doubt that there is anything for themselves in such retrospection?
Jack Waterford is a former Editor of The Canberra Times