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The marketisation of care, at what cost? [AU]

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King, D., Meagher, G. & Uni, S.
Publication Date: 
24 Apr 2009

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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 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.

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. 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 focused 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 critical factors. In turn, these depend on 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.

Focusing on quality begs the question of how pressure can be put on governments to improve the quality of service provision within the care sector. 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.

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.

- reprinted from ABC News