Last week two Royal Commissions with overlapping themes delivered their findings. The Federal Government Royal Commission into Aged Care for the ageing was appropriately painstaking and complex. Its findings were also complex, with the two Commissioners differing on central points. Many of the eventual recommendations were also opposed in submissions by Government Departments and the Minister. The findings were received cautiously by the Prime Minister. The Royal Commission into Victoria’s Mental Health System was shorter and less detailed but no less ambitious. It was accepted enthusiastically in its entirety by the Victorian Premier.
As with all such inquiries the test of their effectiveness depends on how governments act. Past experience offers little confidence. Almost every inquiry has revealed appalling stories of neglect and mistreatment, of underfunding and of demoralised staff. Subsequent inquiries usually show that little has changed. The reason is that people are readily shocked, but their interest is neither sustained enough nor strong enough to accept the fiscal pain necessary for change to take place. Governments therefore talk the talk but rarely walk the walk, fearing that higher taxes will see them being forced to walk the plank at the next election.
This suggests that the precondition of any lasting reform is that the public, including politicians and civil servants, understand both the human reality of mental illness and ageing and what matters in responding to them. Without that understanding any reform is likely to be short-lived and partial.
The Royal Commission into Aged Care emphasised that reform should centre on the human rights of the patient. This is grounded in respect for the human dignity of each human person, regardless of their mental state or capability. A person in advanced dementia is as entitled to appropriate care as is a person in good health. Respect for human dignity entails considering all the relationships salient to a person’s wellbeing and ensuring that they too are built upon respect. They extend beyond keeping persons alive and sheltered to being adequately fed, clothed, clean and provided with medical care. They must also begin with and be supported by good personal relationships with people who have time to care, are sufficiently empathetic and have sufficient knowledge of their condition and needs.
Respect is built on personal relationships and not on services alone. These relationships must be nurtured not only between the people cared for and their direct carers, but also between members of staff, between staff and managers, and between managers and civil servants. They must be characterised by a single-minded respect for the persons who are aged or experience mental illness. Considerations based on managerial relationships of efficiency and economic relationships of parsimony must subordinated to the good of the persons affected.
The challenge of building policy on respect for human dignity can be illustrated by two examples. The first is to give priority to personal relationships, particularly in homes for people who are aged. This points to the importance, for example, of members of staff who are involved in cleaning and in providing meals. In hospitals at an earlier time they often provided the most ordinary and non-threatening casual contact with residents, and potentially important for their wellbeing. If given stable employment and training in building healthy relationships, they could be an important resource.
Yet in the interests of efficiency and parsimony their potential is often curtailed because the funders of the care, whether government, non-government agencies or for profits, outsource them to companies that pay them little, push them to work at a speed that curtails conversation, makes them casual, and reduces their number. In this way efficiency and parsimony are privileged over patient care.
'Respect is built on personal relationships and not on services alone.'
The second challenge to building relationships based on respect lies in the huge number of people who need aged or mental health care. In large systems it is hard to ensure the quality of the immediate personal relationships and to then work out from that.
Respectful care in homes is best assured when built from ground up in small homes with a stable staff, good relationships with the surrounding community and so encouraging visitors and participation from local schools, and an ethos that puts people first in its internal and external relationships. To rely exclusively on such small and highly motivated places, however, would clearly risk leaving a great number of people uncared for.
This means that the government must be involved in providing care, whether by establishing and running homes for aged people itself, by relying on not-for-profit organisations, or by commissioning commercial firms to do so. The temptation is for governments to avoid the complexity of relationships with small non-government organisations and to bring in the ‘big boys’ — the large for profit corporations that can bring all the economies of scale. The values the government wants to preserve, it is argued, can be written into the details of the contract. Less commendably, this solution also allows governments to hide behind commercial in confidence clauses in order to evade responsibility for scandals or sloppy and disrespectful administration. It can evade scrutiny also by hiding the contractual details of what it requires the providers behind commercial in confidence clauses.
The more serious difficulties with this approach, however, lie in the inherent conflict of interest between the commitment of companies to make profits to share with investors and the demands of respect for the aged or mentally ill. The executives of the company will always be under pressure to cut costs and limit services in order to maintain profits. This conflict of interest ought exclude for-profit organisations from government contracts concerned with human services. The distance of management both in the corporations and in government from close relationships to those served in the program, too, inevitably weakens the overriding priority of respect for the people affected.
Not-for-profit consortia which have a strong tradition of respect for people in all their relationships and which respond to the local contexts and needs are a better fit. If they have a strong humanitarian tradition, they can induct their staff to form a community of respect in the daily relationships of the centres. This learning through immersion in a generous community is by far the best, and perhaps the only effective, form of transmitting a culture of respect. It flows out of respectful local relationships in programs and in governance rather than out of legal requirements or top down exhortation.
Reliance on not-for-profit consortia or on the agencies of government to care for people in need, however, is not without risk. It lies in the distance between people in management and those whom they serve. Managers must negotiate costs, contracts and accountability with their funding bodies, including government, and focus on the delivery of services across the organisation. They rarely have the concrete relationships with the people whom they serve through which respect is learned. The demands of funding and the details required in reporting can subtly turn the focus of management away from respect for their clients to parsimony and efficiency. The managerial goal can be defined in narrow economic terms, not the humanity of the people served.
The Royal Commission was right to insist on a human rights focus to aged care. It should also be insisted on in care for people who experience mental health issues. For that focus to remain sharp, however, it must be based in attention by people at all levels of responsibility, political and managerial included, to the concrete human relationships of the people whom programs serve. Would it be too much to ask that all involved as ministers, public servants and managers should be required to spend one day of their working week among the people whom they serve?
Andrew Hamilton is consulting editor of Eureka Street, and writer at Jesuit Social Services.
Main image: Nurse walking with aged person (Cristina Serí/Unsplash)