In 1997 Bronwyn Bishop, then federal Minister for Aged Care, put in place a set of policies and programs that have led to extensive corporatisation of care for the frail elderly in Australia and the adoption of a managerialist model across the sector, both private and not-for-profit. This private industry and efficiency-led attitude in hostel and nursing home care worth many millions of dollars — growing further as the population continues to age — has arrived if not by stealth, then by relatively slow accretion, without its full meaning ever being adequately revealed to the public. Stringent requirements for the care of the aged, with most emphasis placed on physical care through building requirements, forms of risk management and quality systems based on onerous administrative processes, have been imposed progressively over eleven years.
We are just about at the end of the process which placed heavy requirements on building design, and as recently reported, small-scale operators of nursing homes have been closing their doors in droves, unable to meet government requirements and make any kind of profit in the operations they have typically run. In their place, brand spanking new operators have been picking up the slack, offering four star accommodation and efficiency and, the government hopes, excellence in risk management, which includes the management of publicity debacles, the original trigger for Bishop’s policy realignments.
Of course, taking on this problem of risk management opened the door to the Liberal and National parties’ traditional allies — entrepreneurs more than willing to move into new areas of profitability — and an emerging neo-liberal culture of ‘small-state’ solutions: privatisation, commercial exploitation of the service sector and of familial roles, and large-scale corporatisation, with some degree of exposure to world financial markets. Think of ABC Learning’s cutesy teddy bear and higgledy-piggledy ABC block branding (obfuscating?) that multinational conglomerate and you will find some parallels in the branding of some new aged care facilities.
It cannot be denied that in the early days of Bronwyn Bishop there was a class of shonky small-scale operator running substandard nursing homes catering to the poor and abandoned. But on that proper concern has grown not just a solution to a manifest problem, but a comprehensive structure of services oriented in a distinctive way. On the ground — beside the beds and in the sunrooms of nursing homes and hostels — against certain ‘instincts’ of caring (empathy, particularistic relationships and, dare one say, unconditional love) that many care staff and nurses might have, the counter-tendencies of efficiency, profit and risk management have insinuated themselves. Risk management alone conjures up, and indeed does refer to, the existence of a whole culture of caution and managerial intervention in what would otherwise be more spontaneously real relationships between elderly people and care staff who look after them.
Ten years ago some church-run facilities were busy introducing a then thought-to-be excellent model of care: small-scale — say, 36 beds — homelike and personalised circumstances in which regular (not overwhelmingly agency) staff were encouraged and were able, by virtue of the conditions, to give personal attention to people they considered meaningful individuals. Today, the 90-bed institution is the industry standard, as supported by government and prevalent across the sector, with constant mutterings that really only 140-bed institutions are profitable. In turn, to make sure that these large institutions still deliver something like homely care rather than merely efficient nursing, government must encourage large operators to mimic small-scale operations by ‘retrofitting’ homelike physical and psychological conditions, an add-on, which is all they can really be when the basic structure is technocratic and commodified.
In child care, Anne Manne has referred to a process of ‘McDonaldisation’ — US sociologist George Ritzer’s term for a process common across all the contemporary institutions, including education, where what you actually get is not much more than the empty sign of the thing you think you’re getting when the brand appeals to you. Quality, depth, good food, real care, an education: they are all sacrificed to the processes required to make a dollar, while your aspirations are actively managed against imagined lifestyle needs. The McDonaldisation thesis is the classic combination of the Marxist-inspired observation of commodification and the Weberian observation of forms of ‘bureaucracy’, or the science of managing processes to achieve efficiency: purposive rather than substantive rationality (a preoccupation with means rather than ends), although this comes with the bonus today of the magic wrought by the communications revolution and the receptivity of individuals to its messages — here, that care can be bought and that nothing is lost in the process.
The collapse of ABC Learning of course points to a somewhat different experience in terms of the transformation of care — largely a system of state-backed community care — into big business. Here there was no long-term plan and slow increment, but rather an in-yourface hand-over virtually of a whole sector to an entrepreneur without any background and, we might guess, no real interest in the thousands of small children placed in his ultimate care. He certainly had an interest in making money, as did the company’s board members, several of whom were ex-politicians, at various levels of government, of Liberal-National Party ilk. In the context of neo-liberalism’s rapid ascendancy under John Howard, any opposition was muted. Anyone pointing out that child care may not be conducive to full marketisation, or at all, was pretty much thought of as a crank or dinosaur.
It’s only now that an end-point has been reached that pro-state and/or ‘pro-care’ criticisms are being listened to, but even then not very avidly by government, it would seem. If the demise of ABC Learning has shown anything so far (just what set of solutions the government will ultimately put in place is yet to be announced) it is that the Rudd/Gillard government’s first reaction remains the privatisation of child care. Despite months of warning of trouble at ABC, and plenty of time in opposition to devise a preferred structure for child care provision better suited to the needs of children than Eddy Groves’ little red ego (remember the Ferrari), it waited for the collapse and then turned first to the private sector to buy up what of the empire remained financially viable. ‘Extreme capitalism’ may now be Rudd’s trademark critique of what has led to the financial collapse, but capitalism all the same is OK for children’s services, as it is increasingly in aged care. Under Rudd neoliberalism may have a kinder face, but there is certainly no basic revolution here in social thinking about the market or how people might otherwise organise their circumstances, or create new ones, to care for those they love.
Marketisation, and the turning of care into a technical problem to be solved at a system level, tends always to deny the social relational nature, and indeed the depth of the relation as it is carried in face-to-face and embodied relations, that comes into play in caring for another human being. We know that this embodied fullness is part of what makes the care of the very incapacitated an intolerable burden for many people. We know that this is both the joy and the burden of children! Everyone needs relief in circumstances they can’t manage personally; and it may also be of great benefit to the aged mother or the toddler to get a break from the pressure cooker situation of intense familial relations. The question is, what is the best arrangement for doing so, and can the market and its alliance with the science of management be depended upon for real care and concern for dependants?
It’s not that we haven’t had a mixed economy around various forms of care for centuries; and even the hideous penitentiaries of the 19th century — the archetype for modern institutions generally — went part way to marketising care, as do public hospitals and education systems when they employ and pay salaries to private individuals as a system’s labour force. But forms of state-based responsibility for care were not principally of or in a market; and at least in theory the chance for democratic intervention through political processes in the orientation of the institutions, together with mixed arrangements in a sphere that could be called civil society, were possible. In theory, these are checks against the market’s depredating tendencies toward treating people as things, and the attitude of risk management within managerial structures that tends to remove common sense caring from the repertoire of ‘professionals’.
In child care under the Whitlam government (the remnants of which remained when Howard came to power) local community groups and local governments formed cooperative arrangements for some forms of child care or tapped into age-old neighbourhood-type arrangements to employ local mothers and grandmothers in Family Day Care. The state played a key role in establishing the system, but it also tapped into a certain cultural vein at the time, which was about participation and local action and, overall, the idea that ‘small is beautiful’. Child care was not an entirely new arrangement — crèches and day centres had existed for a long time, but there were few, and in the context of women entering the workforce in larger numbers, especially middle-class women, mass child care came to require a broad-based approach to provision. From Balwyn to Sunshine in Melbourne, middle-class and working-class mothers and fathers together with other local women banded together, employed each other as well as trained staff, and in the main ran effective day care centres, with the support of informed community and local government workers with expertise in the area.
Part of the small is beautiful ethos was a reaction against all the modern institutions. In practice, ‘small is beautiful’ required hands-on involvement in the running of services, local political action and local investment, monetary and psychological, at the level of the neighbourhood. While nursing homes were run on a very different basis, with government partially funding nongovernment, often religious organisations, and small-scale private nursing homes operating locally, both the size of operations and their accessibility within communities were somewhat similar to that of child care. Close-to-home accessibility, embodied care and face-to-face recognition among a community of families using a facility were either explicit goals or a practical effect given the scale and type of care provided. Voluntary effort and communal identification were key aspects of this model.
This kind of model where parents are informed and practically concerned in the running of centres looking after their own children, or, for that matter, aged care facilities looking after one’s parents, must have benefits for everyone concerned — the child or elderly person, the mother/father/partner/son/daughter, and even the staff, who may more fully engage with the child or older person if the regimes of efficiency and risk management are allowed to dissipate in favour of an ethical shift that values the whole person. One wonders whether such participation and self-management would be as fully taken up today as it once, however briefly, was in the 1970s. Parents continue to be active on boards of management of some children’s services, including kindergartens and day care centres, but this is not the case in aged care, where commercialisation is extensive and where, even in the case of non-government services, the size and complexity of operations is at such a scale that it militates against non-professional involvement. Whether public participation in services would be welcome, and whether ordinary people would still wish to participate in the way they once did, is unclear.
The problem of the attitude of care being undervalued in modern western society is unlikely to have been solved by turning it into a source of profit making and object of managerial expertise. The question of how services see themselves as providers is crucial. If an overarching ethical attitude guides the care they provide, there may be something of a countervailing force against those depredating tendencies mentioned above. But even then, as in the case of non-profit organisations which have also been forced into large-scale service provision, the battle to remain true to one’s ideals is difficult. Perhaps this points to the proposition that a value or ideal is not sufficient in and of itself. In the face of the re-emergence of the large institution, we might better argue not merely for an ethic of care but see that any such ethic is socially constituted, and crucially underpinned by a realm of human-scale, face-toface and embodied relations.
* This piece of writing is dedicated to Lorraine Walters, who cared for my mother and many others beyond the requirements of efficiency, and whose presence added the intangible, but wholly tangible, element of love to the care provided in the modest nursing home she managed before her untimely death.