Politics, profits and practices in child and aged care

25 Feb 2009

ON AN AVERAGE DAY in Australia in 2006 there were approximately 145,000 people over 65 years of age living in nursing homes. In 2004-05, a further 562,000 older Australians received some kind of formal, publicly funded care at home - 25 per cent more than three years before. In 2005-06, approximately 157,000 people with disabilities received government funded services to assist with their daily activities either in residential or non-residential settings.

In 2006, nearly 700,000 Australian children were in some kind of formal child care, about three fifths of them in long day care, while the proportion of children using formal child care increased from 14 to 23 per cent between 1996 and 2005. Around 174,500 workers in the social care labour force were employed to care for the recipients of these services in 2006 - up nearly 10 per cent from two years earlier. In other welfare service fields, such as child welfare and family support, service use and provision is also rising. Clearly, then, a significant and increasing number of Australians use social care services, and so receive the services of a growing number of paid care workers.

The reasons for growth in provision and employment in social care services are complex - and well-documented. Changes to the social and family roles of women, population ageing, and the increasing incidence of disability all affect demand for social care services. It is now also well-established that public social care services, along with health and education services, contribute to improving living standards and alleviating social inequality. Providing high quality social care on a large scale throws up significant policy and practical challenges, and concerns about availability and quality are central. In the Australian context, where the demand for care outstrips supply, the availability question has been addressed largely by opening care services up to the market.

By 2006 for-profit providers of care ran 71 per cent of long day care places for children (although that figure will have fallen since the collapse of ABC Learning in late 2008) and 31 per cent of residential facilities for the aged. Significantly, what we might call increasing “marketisation” of care services has also involved experiments in “corporatisation,” that is, the emergence - and sometimes withdrawal and even crash - of large corporate entities in care provision. For-profit providers compete for care funding and care places with non-profit (charitable, religious, community) organisations and government services, and they have acquired a significant voice in shaping government policy regarding their regulatory environment. This shift in the economic structure of care provision may not have occurred had greater consideration been given to public opinion; to the voices of those using the services. As data from the Australian Survey of Social Attitudes shows, Australians prefer governments to not only fund but also deliver care.

In childcare, aged care and services for the disabled, people ranked for-profit provision as the least desirable option for formal care. Obviously there is widespread disagreement between the government and its citizens about how paid care might best be organised. Concerns about the market orientation of care policy often focus on what is often referred to as the “inherent tension” between the purpose of the market and the purpose of care. Particular concerns arise with corporate care provision, because corporations are, by law, required to put the needs of shareholders first. Where does this leave the children, the aged, and people with a disability? How can families and governments ensure that the needs of those requiring care are being met? While quality in care provision is often taken to be about meeting measurable outputs such as staffing ratios, it is also about the less tangible elements of care such as the quality of interactions and the feeling of being cared about. Such care requires continuity, consistency and the capacity to interact with others in an "attentive, responsive and respectful manner."

In many ways, the quality of care depends on the skills and experience of the care worker, and how their work is organised, which means the qualities of the workforce and the quality of jobs are also critical factors. In turn, these depend upon the how provider organisations are funded and the policy framework within which organisations operate. Within paid care, then, the issues of availability and quality are intertwined with the politics of regulation and the profits and practices of care providers. It would be foolhardy to suggest that these issues about quality are isolated to the for-profit sector; or that they are indicative of all care providers in the for-profit sector. Indeed, some would argue that market principles have also spread to care providers run by not-for-profit organisations and government bodies through practices associated with the ‘New Public Management’ (NPM).

Modes of management which emphasise cost minimisation, risk aversion, efficiency and objective measurements of outcomes are now widespread across care providers. Within this framework, accreditation becomes a metaphor for quality and economic considerations come before those of the people using the services. Yet there are differences between service providers - and these may not always be a consequence of whether or not they are for-profit. The need to develop a competitive edge in a field of large corporate and non-profit entities means that smaller service providers, whether owner-operated for-profit, or community-managed non-profit, are likely to offer something different, and are often well placed to offer services that emphasise those intangible elements of care. Proponents of NPM argue that market orientation, via competition and enhanced “customer focus,” will maintain or drive up quality, while containing or reducing costs. However, relying on the market alone to improve quality is likely to be a limited strategy. This begs question of how pressure can be put on governments to improve the quality of service provision within the care sector.

Although governments remain the major source of funding for care services, and implement the regulatory framework, there is a risk that the colonisation of care by the market and market logic will result in paid care being depoliticised. In other words, the quality and quantity of care services and care work jobs may come to be (seen as) outside the domain of democratic deliberation and active policy intervention. For care advocates (for example, peak body organisations) and the families and consumers of care services, a big question is the extent to which they have information about the quality of services upon which to base campaigns to improve services and jobs.

The absence of publicly available, comparable information is partly an effect of the difficulty in measuring the kinds of inputs and outputs that genuinely indicate the quality of care. But detailed information about care services is also unavailable because care providing organisations have no incentive to provide it, beyond meeting government requirements or shareholder needs. Trying to engage in political processes without good information would be extremely difficult and probably unproductive. Another source of pressure for quality improvement could come from care workers. In Australia care workers have traditionally been advocates of the value of the relational and more intangible aspects of care. This is a central component of their job satisfaction, regardless of the kind of ownership structure they are employed under. However, the extent to which they can influence the quality of care beyond their own practices - to politicise issues relating to quality - is unclear.

How marketisation of care can depoliticise care workers is evident in countries such as Sweden. Historically, universal welfare and care regimes have been the norm, and governments have been responsive to the needs of citizens, resulting in care systems characterised by high quality and universal availability. However, as market influences have been introduced into the care sector within these regimes, evidence suggests that employee-citizens working in for-profit organisations are less likely to see government intervention as relevant and important for how care is organised and delivered. Which strategies might counter the depoliticisation of care workers, consumers and families, and who might pursue them, are cross-cutting themes throughout this volume.

In Paid Care in Australia: Politics, Profits, Practices, our purpose is to explore, though analysis of child care and aged care systems in Australia, how economic and organisational changes, most notably the expansion of private sector providers into social care, are affecting the politics and practices of paid care. The book opens by providing a context for thinking about questions relating to the institutional and policy arrangements within which paid care - in particular for-profit provision of paid care - is organised. Gabrielle Meagher and Natasha Cortis map the care terrain and delineate the territory within which for-profit providers of paid care operate. Based on analysis of existing research, and mindful of debates about the “inherent tension” between maximising profit and providing quality care, they carefully examine the strengths and weaknesses of for-profit provision of care and what the similarities and differences are in various fields of social care. They argue that, while there may be some evidence against for-profit provision of care, overall the distinction between for-profit and non-profit is too ‘coarse-grained’ to be useful. Bob Davidson gives some insight into why this may be so, with an analysis of the managed market framework through which social care is delivered in Australia.

The government uses managed markets to encourage competition between care providers in the process of distributing funding for care provision. Davidson argues that how markets are managed has implications for the emergence of for-profit organisations, the power of users in the “market,” and the behaviour of both for-profits and non-profits in providing a service. Given this, the government has both the power and responsibility to ensure that markets are managed to achieve good service quality, rather than being focused on the micro-management of short-term outputs. Davidson reiterates the findings of Meagher and Cortis in noting differences within types of ownership as well as between them. These observations hoghlight the need to take account not only of the type of ownership, but also of differences in the sector within which care is being provided - aged care, child care, child protection, care of people with a disability - and whether or not the care is being provided in an institution or within a private home. These all have implications for the delivery and quality of service provision, various aspects of which are taken up in each of the remaining chapters.

As noted above, the two sectors of care provision we address throughout this book are aged care and child care, with the main focus being on care provided within an institutional setting. Rolf Gustafsson and Marta Szebehely open a section of the book dealing with the organisation and experience of aged care work. The first two chapters in this section analyse data gathered in surveys with care workers (including nurses and personal carers) to see what differences, if any, that ownership type means for their quality of work. In contrast to Australia, Sweden is generally regarded as a prime example of a welfare state with universal provision of public social services.

However, in recent years there has been a trend toward outsourcing aged care through competitive tendering, which has resulted in the emergence of for-profit providers. Gustafsson and Szebehely explore whether workers in state-based and in privately owned elder care facilities assess their work environments differently. They also analyse workers’ views on the role of the state in the provision of elder care. Here they find quite stark differences between workers in public and private organisations, and their findings illustrate how marketisation can lead to depoliticisation.

Debra King and Bill Martin also analyse the impact of ownership type on the experience of aged care workers, this time in relation to residential aged care facilities in Australia. They find that for-profit facilities have fewer staff per bed, younger personal care assistants, higher vacancies (particularly for registered nurses), more use of agency staff, and higher staff turnover. Like Gustafsson and Szebehely, King and Martin also find that ownership type had little impact on workers’ experience of, or satisfaction with, “doing” aged care work. They argue that this apparent contradiction between the objective and subjective assessment of for-profit organisations might be partially explained by management practices which enable workers to achieve a reasonable balance between caring for their aged residents, caring for their children and working in a caring environment (that is, good relationships between co-workers).

Jane Mears examines some of these management practices from the perspectives of both care managers and care workers in a non-profit organisation. In discussing how working relationships are negotiated, Mears identifies several tensions around the boundaries of care work: in particular the extent to which the emotional and relational dimensions of care work can be enacted within an organisational context. Her research illustrates a central dilemma in paid care work between care and employment and Mears sensitively addresses both sides of the issue. The three chapters in the book’s section on child care continue the discussion about the relationship between quality care and the market provision of care, but are more focused on outcomes for care recipients: children.

The first two chapters examine the factors that influence parents’ ability to shape the quality of early childhood education and care. Jennifer Sumsion and Joy Goodfellow begin from the premise that the market oriented system of childcare provision in Australia has led to an emphasis on availability rather than quality. The difficulty of shifting the focus to quality is evident in their analysis of the barriers to effective intervention arising from demand- and supply-side imperfections in the child care market. Nevertheless, they argue that demand-led improvements in child care quality are feasible, although they require a more complex understanding of parents as consumers. Bronwen Dalton and Rachel Wilson draw attention to the role of the mass media in shaping parents’ knowledge about and perceptions of childcare. Their empirical analysis of newspaper articles about child care reveals that the media overwhelmingly reported on market issues such as the supply, demand and financial aspects.

Where quality was reported, it was likely to be about issues relating to structural quality, such as ratios and health and safety, rather than about process quality. This lack of emphasis on process - which includes issues such as staff skill levels, curricula and learning opportunities - means that parents are rarely provided with opportunities to consider quality in these terms. In recognising the issues for demand-led improvements in childcare, Dalton and Wilson argue that small non-profit childcare providers have a key role in advocating with, and on behalf of, parents to improve the quality regime. In the book’s final chapter on childcare, Frances Press and Christine Woodrow trace the impact of corporatisation of children’s services, raising questions about whether the market led approach to child care has resulted in positive outcomes for the process dimensions of care quality or for the professional identities of child care workers.

Written at a time when ABC Learning, and its related companies, was the “giant” in the childcare playground, they ask whose interests were being met by creating and supporting such large and complex corporate identities in a care sector. One outcome of the corporatisation of childcare has been the diminution of the public space within which issues such as quality can be raised and debated. Press and Woodrow seek to extend that public space to provide a forum through which parents, teachers, care workers, non-profits and owner operated facilities can participate on their own terms about issues that concern them. While it is common for edited collections from Europe to cover multiple care sectors, it is far less common in Australia. Perhaps this reflects the ways in which different sectors of care are segregated into specific departments and policy areas in this country.

Nevertheless, we believe that there are advantages to be had from combining them. We hope to encourage the cross-fertilisation of ideas across sectors and, perhaps, to help initiate what Deborah Stone calls a “new care movement.”

This is an edited extract from Paid Care in Australia: Politics, Profits, Practices, edited by Debra King and Gabrielle Meagher (Sydney University Press 2009). Photo: Andrew Jeffrey

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