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Focus on human relationships needed for aged and mental health care

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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.

Main image: Nurse walking with aged person (Cristina Serí/Unsplash)

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 HamiltonAndrew Hamilton is consulting editor of Eureka Street, and writer at Jesuit Social Services.

Main image: Nurse walking with aged person (Cristina Serí/Unsplash)

Topic tags: Andrew Hamilton, RC, aged care, mental health, human rights

 

 

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Existing comments

Well said, Andrew. Pre retirement I was a health manager in aged care. In retirement I drive a nursing home bus. I have learned so much in the role. A few big wigs should joint me lol.
Ross Bell | 11 March 2021


I like the final suggestion of getting the decision-makers to do at least one day of their working week at the aged care home. It's like a reality check, to keep them focused on the essential charter of aged care- providing care for the elderly.
JOHN WILLIS | 11 March 2021


Spot-on, Andy! The recent first hand account, submitted by letter to The Age (March 5, p. 29) expressing the anguish of parents who lost both their children to mental illness-induced suicide, should be enough to raise alarm bells about the impersonal and over-clinical nature of the services we provide for the mentally ill as well as frail-aged. Many of us who have experienced the impersonalistic and 'remote-controlled' nature of modern communication and help-seeking ('Press Button A; now press Button B') will be all too familiar with the dehumanising aspects of service delivery, resulting at best in the hapless responses of Centrelink staff whose main line of defence is to point to signs warning irate 'clients' that any stroppiness will result in prompt ejection by overly-pumped security staff. That the use of such bizarre 'props' at service delivery centres suggests a reduction of interactive discourse on sensitive matters, frequently involving the exchange of personal information on an emergency basis, is akin to the wide berth we used to give those priests in the confessional whose remonstrations used to boom around every cathedral and church that I snuck into for my youth-entrapped unburdening. Spending time weekly at the coalface is de rigueur!
Michael Furtado | 11 March 2021


It's not so very long ago that many aged and ailing parents were cared for at home for as long as possible at by their grown children. This practice underlined the value placed on family and the responsibility of family members to care for their own. The economic discouraging and dislocation of extended families we experience increasingly today deprive the vulnerable of God's most natural support resource and the personal relationship Fr Andrew recognises here as vital in caring for the aged and vulnerable. Time to make family a priority in our moral, social, political and religious thinking and practice?
John RD | 14 March 2021


You have hit the nail on the head, John RD, and described yet another of the great failures of today's erstwhile Judeo-Christian civilisation in the wake of the selfishness and godlessness that has overcome the last two generations.
john frawley | 14 March 2021


Families come in all shapes and sizes and the best caregivers in any settings are those whose values reflect those of the best families. That said, there are also dysfunctional families, just as there are dysfunctional care-givers and, saddest of all, dysfunctional churches, surely?
Michael Furtado | 15 March 2021


You are Andy, like John RD and John Frawley, one of those little lights in the darkness, reflecting that Greater Light of God. There is a form of the family, reflecting the Form of that family in Galilee. My current take on the situation is that there is enough residual Christianity within our current society, which, if tapped into, can redeem that society as a whole. My wife is a resident in what would appear to be an extremely good nursing home. They do exist. It's a bit like during the bad days of child sexual abuse there were many exemplary priests who were not involved. God did not create a totally evil world. It was morally ambiguous. Christ changed that. Forever.
Edward Fido | 16 March 2021


We need to understand the neglect which is prevalent and ongoing. Basically it is in denial of ageing and death. We don't deny the frivolities of fashion, sport or fast food. Decline in old age is almost only discussed by those experiencing it. So like the lepers of old, aged people are parked at the gates of the village. Keeping people at home as they age is the most humane and economical way to go. But that would mean healing family rifts, mending parental relationships, sharing the loads with properly trained trained outsiders and maintaining relationships in the community. It used to work. There is no way to make a profit from decent aged care. Unless you charge a huge fee and then you have two separate classes of aged. And 'not for profit' organizations are not all the innocent organizations depicted, Andrew. Often they cream off funds for their own comfort. Check their offices, cars and percentage services charges they exact. Currently we have the system we want. We want to deny ageing. We want to deny it is an ongoing process of letting go of who we are. We want to keep them out of site. We want to throw money at them instead of being beside them. The market can't sell them much so bugger them. Except to put them into an expensive, unregulated, greedy filing cabinet separate enough from us all to deny they exist.
Michael D. Breen | 17 March 2021


Thank you for your very kind and gracious acknowledgement, Edward. My mother, widowed at 80 and this year in her 100th year, is now in excellent care at a United Church nursing home nearby. I'm sorry to learn of your wife's condition, and will pray for you both.
John RD | 17 March 2021


I should qualify my comment above by adding that there are those people who require care that cannot possibly be provided by family in a home environment even with the currently available in-home care services. It is these people who require specialised care services in the nursing home sector. One of the big problems we have is that there are many in nursing home care who are there not for their benefit but for the benefit of "family". As with euthanasia we now live in a society which legislates not for those suffering but for the effects their distress has on others to whom they have become a burden or in whom their situation generates inconvenience or unpleasant, socially limiting demands .
john frawley | 17 March 2021


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