The Roots of the Aged Care Crisis

Australia’s aged care system is in crisis. Evidence of abuse and neglect in residential facilities has been mounting in recent years. As with the NDIS, the starving of a public system has provided justification for the introduction of marketisation and privatisation. Caring for the aged  has been absorbed into a broader neoliberal ideology, and the sector is groaning under the cumulative impacts of profit-making at the expense of care, the systemic devaluing of reproductive work, care work, and people in the ‘post-productive’ stages of their lives. For those of us with parents or grandparents entering the aged care system, these decisions are bound with guilt and fear.

Since the 1980s, these trends have led to a shift towards a more market-driven approach to the provision of aged care, predicated on consumer choice and control. ‘Consumer-directed care’ (CDC) has been introduced formally in the last decade, purportedly on the grounds of empowerment, self-direction and self-funding - monetising the lives of those not longer working. The introduction of the Aged Care Act 1997 ushered in a ‘user pay’ principle, requiring people entering residential care to pay a means-tested client contribution. The Act itself focuses primarily on government funding arrangements, at the expense of standards of care, which had to be introduced in later legislation. The sector is currently undergoing a range of reforms as a result of the Productivity Commission’s 2011 Caring for Older Australians report, which again shifts the sector towards user-pays and marketization models. Private, for-profit providers now constitute 40% of residential aged care places.

However, prioritising the profit motive has undermined care in the sector. For-profit organisations are more likely to breach care standards. The impacts on staff and labour conditions have been stark. Alongside low rates of pay, poor workplace conditions, and a high turnover of staff, the sector has undergone a ‘deprofessionalisation’. It is predominantly staffed by registered and enrolled nurses, personal care assistants (PCAs), and temporary agency-based workers, requiring levels of training varying from a Bachelor degree to a Certificate III or lower. But there has been a substantial decline in the number of registered and enrolled nurses in the aged care sector, representing a loss of skills. Personal care assistants, rather than licensed nurses, constitute nearly 70% of staff in the aged care sector. Aged care work has been situated as an ideal opportunity for an unskilled workforce, making used of feminine notions of care to justify low pay. As a result, the sector is burdened by a lack of appropriately trained or qualified staff, often unable to meet the complex needs of older people, or to provide holistic, relationship-based care. These workforce issues indicate the failure of aged care policy, funding and legislation to deliver a stable, skilled workforce that can meet the needs of ageing people and an ageing population.

Aged care work has been situated as an ideal opportunity for an unskilled workforce, making used of feminine notions of care to justify low pay. As a result, the sector is burdened by a lack of appropriately trained or qualified staff, often unable to meet the complex needs of older people, or to provide holistic, relationship-based care.

Given that the sector is burdened by ongoing resource, funding, and staffing shortfalls, there is a high possibly that some abuse is the result of a stressed, deprofessionalised and low-paid workforce. Aged Care Minister Ken Wyatt said earlier this year, "What we've seen around this country is that … staff who have been trained in a very short timeframe, and who have not had hands-on experience, struggle". This deprofessionalisation sits alongside the pressures of an overworked and stretched workforce. The Australian Nursing and Midwifery Federation describe a situation of “chronic understaffing” and staff have described being too busy to provide dignified care to residents. The ONMU argue that chronic understaffing has resulted in a 400% increase in preventable deaths in aged care.

Meanwhile, private, for-profit providers pay minimal tax and post huge profits, while also taking advantage of taxpayer subsidies. The Tax Justice Network reported that Bupa, Australia’s largest for-profit provider, uses a complex corporate structure in order to minimise taxable income and taxation, paying just $105 million on a total income of $7.5 billion in 2015/16. At the same time, the top six for-profit providers received $2.17 billion via government subsidies.

The crisis in the sector has not gone unnoticed, but it is a huge task to turn it around. Recently, opposition leader Bill Shorten described the aged care sector as a “disgrace” and a “national crisis”. Policy responses have included the introduction of mandatory reporting of elder abuse by the federal government in 2007 and this year, the government announced the introduction of an ‘Aged Care Quality and Safety Commission’ to monitor aged care facilities in the wake of revelations regarding abuse and breaches of standards. However, increased monitoring and reporting avoids attention to the substantial systemic issues facing the sector. Rather than investing in staff, quality infrastructure and training, such approaches take the perspective that with more information, the aged care ‘market’ will sort itself out. Meanwhile, the ANMF have been campaigning for staff ratios, and the HSU have been campaigning for more funding.

The federal government has recently begun a royal commission into the aged care system. However, the principles of “choice, control and independence” are embedded in the terms of reference, indicating that privatisation will remain at the core of aged care. No attention has been given to the impacts of privatisation on the sector, and the people in its care. The royal commission has already received hundreds of submissions, many of which focus on staffing ratios and substandard care.

Rather than investing in staff, quality infrastructure and training, such approaches take the perspective that with more information, the aged care ‘market’ will sort itself out.

The crisis in residential aged care sits alongside a broader crisis in care work, reproductive work, time-poverty, and the value of people in old age. Time and monetary pressures prevent many of us from engaging in communal and informal forms of care, be it for family, neighbours, or friends. Car-based neighbourhoods rob many older people of the ability to fully take part in their communities. Limited payments and support for carers can leave families stretched or destitute. Ongoing pressures on aged pensions can leave people facing poverty in late life, increasing the likelihood of mental and physical illness. These pressures suggest the need for not only socialisation and increased funding to the aged care sector and workforce, but broader transformations such as shorter work weeks, people-centred planning and investment, accessible public transport, and generous social supports. This could help to shift the dial from profits to people and from corporations to care, giving everyone, both young and old, the time and space to invest in their families and communities. As evidence of this crisis mounts, intergenerational solidarity is vital.   


Amy MacMahon is an organiser and sociologist living and working in Meanjin/Brisbane, with interests in community development, social work, climate and food justice and feminism.


Photo by michael schaffler on Unsplash