Is Choice the only Fruit? – Hearing Older People's Voices
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The document discusses choice and voice for older people in aged care policy in Australia. It debates the benefits and risks of choice as the main policy mechanism, and whether choice alone is sufficient. It also examines the rise of the consumer model and assumptions about older people as consumers. The risks of individualized funding models are outlined, as well as the importance of collective voice mechanisms. Finally, the document calls for further research on the perspectives of diverse groups of older people regarding choice and voice.
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Is Choice the only Fruit? – Hearing Older People's Voices
- 1. Is Choice the only Fruit? – Hearing Older Peoples’ Voices Australian Association of Gerontology 46th National Conference November 2013 Caroline (Carrie) Hayter PhD Candidate, Faculty of Education and Social Work University of Sydney, Sydney
- 2. Introduction
- 3. Purpose • Debate the issue of choice and voice for older people – Benefits and risks – Is choice the only fruit? • Who is the ‘consumer’? – Assumptions about the ‘consumer’ – What do we know about older people as ‘consumers’?
- 4. Purpose • Policy mechanisms to enact ‘choice’ and ‘voice’ – Lessons from aged care policy history • Further Research
- 5. Methodology • Literature review for PhD – Why choice emerged as a policy issue in community aged care policy in Australia? – Organised voices of older people • Historical perspective – What lessons can be learnt from history?
- 6. Aged Care System in Australia • Mixed economy of care • Hybrid system where informal supported by the formal • Managed Market – Hybrid and Competitive Tendering and Contracting (Davidson, 2011/12) • Limited choice and control for older people (Productivity Commission, 2011) • Power is vested in the provider – Shifting with emergence of ‘consumer’ directed care – Focus on ‘user pays’
- 7. Shifting Policy Landscape – Personalisation Passive Clients Active ‘consumers’ Block funding Individualised funding Rigid large inflexible services Flexible responsive services
- 8. The rise of the ‘consumer’ Consumer as Purchaser Citizen Social and political rightsEconomic purchasing power Relationship between client and professional Client Citizen – Consumer Active or passive subjects? Mechanisms for enacting ‘choice’ and ‘voice’ Market mechanisms via competition (LeGrand, 2007) Managing self interest (LeGrand, 2007) and voice mechanisms Enable ‘choice’ through ‘voice’ mechanisms (Simmons et al 2011) Diversity of policy mechanisms
- 10. Risks of ‘choice’ mechanisms • Older people as ‘consumers’ – Disempowers service users (Barnes and Prior, 1995) – Access to economic resources and information (Glendinning, 2008, Le Grand, 2007) • Marketisation via individualised packages – Access and equity – Individualised budgets low take up by older people in the UK (Glendinning et al 2008, Moran et al, 2013) – Privatisation of care and outsourcing of risks to individuals – Undermines the functions of the welfare state
- 11. What does having a ‘voice’ mean? • Voice – Having more say in services – Individual or collective voice (Simmons et al, 2011) – Voice can go beyond the confines of choice • Relationships • Connections (Simmons et al, 2011) – Exit (Hirschman, 1970) • Voice mechanisms – Complaints – Surveys – Political activity through voting or lobbying – Participation in representative bodies or groups (Simmons et al, 2011)
- 12. The political spectrum of ‘voice’ Liberty - Liberal prioritising of rights minimum state interference State fulfils basic needs Source: Greener, (2008) Right wing Left wing Liberty based on prioritising of need Increased reliance on self help Individual ‘Active citizens’ Collective Interests
- 13. Voice mechanisms in aged care in Australia • Aged care system dominated by interests of professionals, providers and government (Sax, 1990, Gibson, 1998) • Emergence of voice mechanisms in the late 1980s early 1990s – User rights strategies through National Standards – Limited awareness and impact on older people (Gibson, 1998, House of Representatives Standing Committee on Community Affairs, 1994) – Structures for older people in policy processes (Howe, 1992) and hearing older people’s voice
- 14. Voice mechanisms in aged care in Australia • Organised voice of older people through ‘consumer’ groups – Will this translate into changes in practice? • Challenging staff attitudes to ageing • Structures to hear the voices of older people (Barnes & Bennett, 1998) • Appropriate structures for different groups of older people
- 15. Benefits of ‘voice’ mechanisms • Citizenship – Individual and collective mechanisms (Simmons et al, 2011) – Vehicle for politicising older people • Opportunity for engagement – Explore depth of feeling (Simmons et al, 2011) – Collective or group response (Barnes & Bennett, 1998) • Partnerships – Older people and providers co-produce outcomes
- 16. Risks of ‘voice’ mechanisms • Voice alone wont change behaviour of providers (Le Grand, 2007) • Providers may not ‘hear’ the voices of older people – Ignores power differences between older people and providers (Ottmann et al, 2011). • ‘Organised voice’ of older people – Diversity of interests
- 17. Choice and Voice • Moving beyond the ‘consumer as chooser’ • Choice about voice – Reflect the diversity of service users (Simmons et al, 2011) • Parameters of choice – Who, what, when and how (Le Grand, 2007) • Mechanisms for older people – Political structures – Vulnerability of some older people
- 18. Further Research • Research on the perspectives of older people – How different cohorts of older people respond to different choice and voice mechanisms? – Expectations of different older people • Older people from Culturally and Linguistically Diverse (CALD) backgrounds • Aboriginal and Torres Strait Islander older people
- 19. Conclusion
- 20. References Barnes, M. (2009). Authoritative Consumers or Experts by Experience? User Groups in Health and Social Care In R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference, . Bristol: The Policy Press Barnes, M., & Bennett, G. (1998). Frail bodies, courageous voices: older people influencing community care. Health & Social Care in the Community, 6(2), 102-111. doi: 10.1046/j.1365-2524.1998.00105.x Barnes, M., & Bennett, G. (1998). Frail bodies, courageous voices: older people influencing community care. Health & Social Care in the Community, 6(2), 102-111. doi: 10.1046/j.1365-2524.1998.00105.x Beresford, P. (2009). Differentiated Consumers? A Differentiated View from a Service User Perspective In R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference Davidson (2011/12) Contesting Markets, Journal of Political Economy, 68 , Summer 2011/ 2012 Glendinning, C., Challis, D., Fernández, J., Jacobs, S., Jones, K., Knapp, K., Wilberforce, M. (2008). Evaluation of the Individual Budgets Pilot Program York: Social Policy Research Unit Glendinning, C. (2009). The Consumer in Social Care In R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference Bristol The Policy Press Hirschman, A. (Ed.). (1970). Exit, Voice and Loyalty Responses to the Decline in Firms, Organisations and States Cambridge Massachusetts: Harvard University Press Greener, I. (2008). Choice and Voice – A Review. Social Policy and Society, 7(02), 255-265. doi: doi:10.1017/S1474746407004204 Le Grand, J. (2007). Choice and Competition In J. Le Grand (Ed.), Delivering Public Services through Choice and Competition - The Other Invisible Hand (pp. 38-62)
- 21. References Moran, N., Glendinning, C., Wilberforce, M., Stevens, M., Nettens, N., Jones, K., Manthorpe, J., Knapp, M., Fernandez, J., Challis, D., & Jacobs, S. (2013) Older people’s experience of cash-for-care schemes: evidence from the English Individual Budget pilot projects, Ageing and Society 33, pp 826-851 Ottmann, G., Laragy, C., Allen, J., & Feldman, P. (2011). Coproduction in Practice: Participatory Action Research to Develop a Model of Community Aged Care. Systemic Practice and Action Research, 24(5), 413-427. doi: 10.1007/s11213-010-9181-5 http://dx.doi.org/10.1007/s11213-011-9192-x Productivity Commission. (2011 ). Caring for Older Australians, Report no 53, Final Inquiry Report Canberra Australian Government Sax, S. (1990). Development of Public Policy for the Aged. In H. M. Kendig, J (Ed.), Grey Policy, Australian Policies for an ageing society (pp. 23-40). Sydney: Allen & Unwin Schwartz, B. (2004). The paradox of choice - When more is less? New York Harper Collins Publishers Simmons, R. (2009). Understanding the Differentiated Consumer in Public Services In R. Simmons, M. Powell & I. Greener (Eds.), The Consumer in Public Services, Choice, Values and Difference Bristol The Policy Press. Simmons, R., Birchall, J., & Prout, A. (2011). User Involvement in Public Services: ‘Choice about Voice’. Public Policy and Administration, 27(1), 3-29. doi: 10.1177/0952076710384903 Wilberforce, M., Glendinning, C, Challis, D, Fernandex, J-L, Jacobs, S., Jones, K., Knapp, M, Manthorpe, J., Moran, N., Netten, A., & Stevens, M., (2011) ‘Implementing Consumer Choice in Long-Term Care: The Impact of Individual Budgets on Social Care Providers in England’, Social Policy & Administration, 45 (5), 593-612
- 22. Contact Details Carrie Hayter Email: carriehayter@gmail.com Linked in:http://au.linkedin.com/pub/carrie- hayter/34/536/517/ Twitter @carriehayter
Editor's Notes
- I would like to acknowledge the Gadigal people of the Euroa nation whose land we meet on today and pay my respects to elders past and present. I would also like to acknowledge my co-presenters in this symposium who have assisted me in the development of this presentation. The title of my paper “Is choice the only fruit? –Hearing Older People’s Voices questions whether the current focus on policy directions in aged care policy in Australia is focusing too much on ‘choice’ at the possible expense of the policy mechanisms that could promote the voice of older people. In this paper I will refer to the voices of older people because there is no one voice or organised voice that represents the interests of older people.
- I want everyone to imagine that you have this enormous fruit platter sitting in front of you. Some people in the room will choose to eat the strawberries because this is what they prefer. Other people will eat pieces of lots of different types of fruit. Some people may be struggle to make a choice because of the fruit that is on offer. Others may ask where are the tropical fruits like mangos, or stone fruits, whereas others will just accept what is served and dished up to them. Some people argue that choosing community care is just about expressing preferences like eating fruit. When we look at the issue of choice and voice – is it as simple as choosing a piece of fruit from a fruit platter?
- In todays paper I want to explore some of the tensions that emerge in the conceptualisation of choice and voice. I will touch on some of the issues and criticisms of the issue of choice as a means for introducing the idea and concept of voice. As part of this debate I will explore this vexed issue of the emergence and rise of the ‘consumer’ as a central figure in the reform of aged care policy in Australia. In focusing on this area I hope to question some of the ideological and political assumptions that underpin how older people as ‘consumers’ are being described in Australia.
- What are the risks and benefits of different policy mechanisms that promote choice and voice? Who benefits? Who does not benefit? What are the risks of particular mechanisms and how does this effect the historical institutional structures upon which Australia’s aged care system is based. I will also pose questions for future research that focus on the interests, preferences and voices of older people and for researching the impact of changes in policy mechanisms that aim to promote choice and voice for older people.
- This paper is based on the literature review I have been completing for my PhD research which is examining why choice emerged as a policy issue in community aged care from a historical perspective and how the voice(s) of older people were represented in the construction of the community aged care system in Australia at key policy turning points between 1975 and 2011. From a historical perspective, I am interested in exploring how choice emerged as a policy issue and what are some of the lessons from looking at key policy turning points in aged care policy history. I am interested in exploring how older people’s voices have been represented and the emergence and construction of the ‘consumer’.
- There are significant changes happening in the policy landscape in age care and disability policy in Australia as part of the agenda of personalisation. The assumptions that underpin these shifts include the changing role of people who use public services shifting from being ‘passive’ clients to ‘active consumers’. It is assumed that people who use public services or aged care services will become active ‘consumers’. Rather than being passive clients relying on professionals for support and advice people are assumed to be active engaged ‘consumers’ who will make informed choices about their care. Flowing from this assumption is the need for changes in the how agencies are funded from block funded to individually funded. It is assumed that individualised funding will provide more mechanisms for service users to get their needs met. We are seeing this funding system emerging as part of the launch sites of the NDIS as well as the emergence of the concept of ‘consumer directed care’ in packaged care in aged care in Australia. While there is evidence of some of the benefits of personalisation from different stakeholders including older people, people with disabilities and their carers. There are also some significant risks and areas of evidence which are contestable and disputed, particularly some of the assumptions about ‘choice’ and ‘voice’ and the mechanisms that promote choice for service users.
- The policy mechanisms for enacting the issue of ‘choice’ are framed by how we view people are ‘service users’. For those who argue that people who use public services are ‘consumers’ then they favour the creation of markets through the introduction of competition to drive efficiency and effectiveness and services to be more responsive to the needs of consumers. In this economic framework there is also the possibility of co-production where purchasers and producers co-produce outcomes for the interests of service users For those that describe people who use public services as clients. The policy mechanisms are about managing the perceived self interest of the bureaucracy and challenging the paternalism of the welfare state. This can be achieved through competition and the creation of markets but also through voice mechanisms For those who conceptualise service users as citizens the focus moves away from purchasing power to notions of social and political rights and for people to have choice about the voice mechanisms that are introduced. There is also the hybrid citizen –consumer whose relationship with public services can change over time. People can be both active and passive subjects and there needs to be a diversity of policy mechanisms not just those that shift the user of public services to be a ‘consumer’.
- The concept of choice is a politically loaded topic because choice can mean different things to different people. If we think about the different stakeholders in aged care, choice means different things to the different actors For older people who are service users it may be about having respect or being able to make decisions about what matters most for them to have a good life. This may include choice of staff, service, provider and the type of supports that are provided. For service providers– choice may mean having the right staff, having mechanisms to hear the voice of older people. It may also be about delivering a return on investment to share holders at the end of the year and making a profit in a marketised economy. For government, they often seen choice as a vehicle to drive efficiency and effectiveness, however, framed in a human rights discourse. While the policy discourse talks about ‘choice’ and ‘control’ for older people, the underlying agenda is an economic argument about the costs of care. In this there can be the merging of the interests of service users interested in dismantling welfare paternalism which works to further the ‘choice’ agenda.
- There are a number of risks of ‘choice’ mechanisms. Some argue that the move from citizen to consumer can work to disempower service users. The ability to act as an informed consumer is conditional on information as well as having access to economic resources to make systems work in your interests The issue of shifting to a more individualised approach can lead to issues of access and equity. There can be significant differences between people in terms of who gets what and how these are delivered. Research from the evaluation of individualised budgets identified there was low take up by older people. This begs the question as to why we are implementing this model in Australia There is the potential within a more marketised and individualised world of the further privatisation of care and outsourcing of the risk for the management of packages to individuals. This can therefore undermine the collective social interests of the functions of the welfare state.
- Given the risks of mechanisms promoting choice then perhaps it is about focusing on voice. What does voice mean? Simmons argues that voice is about ‘giving users a more effective say in the direction of services, by means of representative bodies, complaints mechanisms and surveys of individual preferences. According to Hirschman it can also be about exit whereby people choose to exit a service because they are dissatisfied. This, however, is tricky in aged care because there is often nowhere else for people to exit. Voice can also have a political focus through expressing wishes and preferences through voting or participation in political parties or representative bodies. Simmons argues that voice can go beyond the confines of choice because it allows people to express their preferences or feelings about a particular issue. This can also be undertaken as part of the membership of a group which can increase the impact on political processes and outcomes. Rather than being a consumer who expresses their individual preferences in the market, people can express their preferences through relationships with other people, providers and groups. It concept of voice and the mechanisms to promote voice are therefore often aligned with the concept of citizenship.
- There is also a political spectrum of the concept of voice. At one end of the political spectrum the concept of voice is based on liberty and freedom based on the assumptions of ‘active citizens’. This perspective actually argues for minimal state interference and increased reliance on self help. At the other end of the political spectrum voice is based on the concept of liberty but about prioritising need. It is the role of the state to intervene and fulfil the basic needs of people. Voice can be a means of expressing the individual and collective or organised voice of older people.
- Australia’s aged care system was created largely in the interests of professionals, providers and government and has a legacy of older people being seen but not heard. During the mid to late 1980s there was the awareness of the need to engage with older people. Some of this was largely in response to the abuse of older people in nursing homes. As part of this process there was the introduction of national standards in nursing homes and community care programs. This included the development of user rights strategies by government and statements of rights and responsibilities in the Home and Community Care program. However, evaluations of these strategies identified that they had little impact on older people. The reasons for this are not clear, however, perhaps this was because they were implemented by government ‘to protect’ older people rather than older people demanding some of these changes. During the mid to late 1980s and early 1990s there was the establishment of consumer consultative forums. These structures were created by government to hear the voices of older people and this included the creation of Offices of Ageing to raise the profile of issues of ageing within government and in the community. This was a period of significant shift, however, there is some debate about the impact of these structures on policy outcomes for older people
- There is an increasing awareness and activism in terms of the organised voice of older people as a political force, however, this needs to translate into changing how agencies work with older people. I think there have been some significant changes, however, there is more work to be undertaken. Research by Barnes which examined creating user groups for older people in Scotland highlighted the benefit of connecting older people via organised groups. This research highlighted the resistance of providers in hearing the feedback from this group of service users about how the local home support service was provided. While consultative structures can be created the extent that providers and government with entrenched interests want to hear the voice of older people may be debated. There are also differences in power between providers and older people and this needs to be considered when looking at appropriate voice mechanisms. There needs to be a diversity of mechanisms to reflect the diversity of older people. The mechanisms to engage and hear the voice of Aboriginal people or older people who identify as LGBTI may require a different approach.
- The concept of voice is based on the idea of citizenship and that older people have social, economic and political rights. It can therefore be a mechanism for older people to express both their individual preferences and their views in terms of collective groups or interests. In this sense, it views older people as part of the social, economic and political life rather than being reduced to a person who purchases services in the market that tends to downplay the collective interests and responsibilities of older people. Some people argue that this move towards consumer directed care presents an opportunity for older people and the agencies that support them to work together to co-produce outcomes. However, others such as Barnes remind us of the importance of understanding how service users, particularly older people, may not see themselves as equal partners with agencies that support them.
- There are some risks of relying on voice mechanisms. Le Grand (2007) argues that because of the entrenched self interest of providers, voice mechanisms alone will not change the behaviour of providers. In order to change the behaviour there needs to be external incentives including competition between providers for funding to ensure they respond to the interests and wishes of service users. In terms of aged care in Australia, it has only been recently that consumer directed care has emerged largely in response to government policy changes rather than the demands from service users. Perhaps this suggests that voice alone wont change behaviour. While providers and government may create structures to engage with older people, this may not necessarily translate into actual changes in practice or policy. If mechanisms to encourage the voice of older people are to be considered then there needs to be consideration of the power imbalance between people who use services and those who provide them. Australia has a long history of active engagement of organisations in the political and lobbying process over the history of aged care policy in Australia. Some of these organisations have been instrumental in advocating for significant policy changes, however, there may be questions about whose these groups represent. There may not be one voice but many voices and ensuring these voices are heard is important. Older people are diverse and having a range of organisations that represent the diversity of older people is an important consideration.
- Given the limitations of choice and voice. Perhaps it is about ‘choice’ about ‘voice’ and the use of diversity of policy mechanisms Le Grand (2007) has developed a schema for some of the parameters of choice in terms of service provision including the who, what, when and how of choice to provide some control or option for service users We also need to really examine the mechanisms for older people to participate both as service users but also as citizens and recognising for some older people the nature of being a ‘service user’ may be a point of vulnerability.
- There is certainly more research that needs to happen to understand how older people experience some of the proposed changes in relation to personalisation. For example are there differences between different cohorts of older people including people that are 80 years old and those who are 65 years old. The life experiences of these older people can be quite diverse What does some of these changes mean for people form different cultural and language groups and for Aboriginal and Torres Strait Islander older people.
- Choice is not the only fruit Voice can be a mechanism for more ‘choice’ Given the historical institutional structures of the aged care system in Australia perhaps there needs to be more discussion about the mechanisms that promote the voice while encouraging people to have a more constrained choice. Perhaps it is the case that people need to have ‘choice’ about their ‘voice’. Policy dialogues need to ensure that the mechanisms enacted can respond to the diversity of service users and not just focus on the assumption of the service user as ‘consumer’. We need to be clear about what are the trade offs in the pursuit of providing more ‘choice’ or ‘voice’ for older people as service users.