"We'll have 15 six-bedroom homes and each looks different so the residents can visually orientate themselves." The village, from not-for-profit Glenview Community Care, will have shops, a cafe, a beauty salon and a cinema all accessible to the local community. "It's what you and I take for granted," O'Flaherty says. Revenue from these commercial operations will flow back into the aged-care operations. Lucy O'Flaherty runs an organisation proposing to build an innovative nursing home modelled on a village. Photo: Rob Inglis/ Credit:Rob Inglis / The Examiner

Korongee takes after a ground-breaking Dutch dementia village, Hogeweyk, and is the opposite of the medicalised institutions in which most Australian dementia sufferers will live out their final years. Hogeweyk's philosophy reflects the idea that, after a full life of making their own decisions, even people with dementia can still "have a valid opinion on their day-to-day life and surroundings". O'Flaherty says existing facilities could draw from what will be built at Korongee to make them better places in which to age. "If you de-stress the environment, you change the experience. Stress only accelerates the decline." O'Flaherty, Glenview's chief executive, says the project has already formed a strong bond with the principal of the neighbouring high school, which soon would be able to say to its students, "Guys, there's a job over there for you.

"We want to change the myth around aged care [that it's a terrible place to work] and say, it's not just personal care work – we have accountants, gardeners, administrators, hospitality." Glenview's is an upbeat view of the future of aged care. But there are plenty of challenges confronting policymakers and ageing Australians. By 2050, more than 5 million people – the Baby Boomers – will need access to aged care. Just to house them, the industry will need to spend $33 billion in the next 10 years on building new facilities and refurbishing existing ones as they become run down.

Aged care's share of the total economy will double to 1.7 per cent, "largely due to the increase in the number of people aged 85 and over", according to the last federal budget. The expansion in cheaper home care packages, and the desire of people to stay at home longer, means they will arrive in aged care sicker and needing more intensive treatment. The number of staff required to fill this need will triple – it will cost taxpayers $100 billion in the next five years alone. About half of the beds currently available in nursing homes are in shared bedrooms and, according to Cameron O'Reilly, the chief executive of the for-profit provider lobby group the Aged Care Guild, "this won't be acceptable" in future. This throws up two challenges: how to care for people better, and how to pay for it.

Optimists believe the future of care in nursing homes will virtually look after itself. "There's a view that the Baby Boomers are going to be far more strident [advocating on their own behalf] and they will reform the system as they go through it," says Monash University professor Joe Ibrahim. He disagrees. "Even if you're the prime minister and you're 80 or 90 and in residential care, and have dementia, your ability to formulate an argument and stand your ground, to not be concerned about the impact on others isn't there any longer," Ibrahim says. It's hard for us to imagine what it's like being totally dependent on hired hands for our most intimate needs, Ibrahim says, and it does not encourage assertiveness.

Community advocate Lynda Saltarelli​, of Aged Care Crisis, is frustrated that of the dozens of reviews, consultations and parliamentary and expert inquiries that have been held over the years, few of them focus specifically on the issue of care. To her, a significant failing of the system is that the community is locked out. Nursing homes control entry and can – and do – exclude people including family members they believe are troublesome. "The government and industry own the system, the families don't," she says, so when there's a complaint, "it's families versus nursing homes and government." Family members feeling alone and ganged-up on by a complex system then become aggrieved, frustrated and sometimes shrill. She says family members, retired nurses, volunteers, community members "should be at the centre of it". Under this model, "which we're calling, for want of a better word, 'a Community Aged Care Hub'," Saltarelli says the government would work with the community, which would then manage the oversight of nursing homes, advocacy for residents and complaints handling.

The community would work with the nursing homes, collecting accurate data about staffing, standards of care and quality of life, then pass that on to families and potential residents. Lynda Saltarelli of Aged Care Crisis says the community has to be involved in governance. Photo: Eddie Jim Credit:Eddie Jim "To be effective, the community hub would need to have sufficient control and power to control the market and make it meet their requirements," Aged Care Crisis wrote in a recent government submission. "They would need the power to decide which organisations operate in their communities … [and] what we propose would create an effective customer and re-engage civil society." Pat Sparrow, the chief executive of the not-for-profit aged-care lobby group Aged and Community Services Australia, agrees that, at the moment, the relationship between the home and the government too often guides the way the homes operate.

She believes that, "If we want to meet the needs of consumers, it's better for the relationship to be directly between them and the home." The market will fix it Like Sparrow, the best thinkers in the federal government, believe putting people ("consumers") at the heart of the equation is the way forward. The government, led by the head of the Aged Care Sector Committee and a former secretary of the federal finance department, David Tune, has produced an "Aged Care Roadmap". It's classic neoliberal economics, and has as its twin credos putting the consumer in charge, and light-handed regulation.

In his roadmap, and a subsequent review of the aged-care legislation, Tune says older Australians in future will want "more choice, control and better access" to services. He proposes making it easier to move between the home care and residential care systems and removing "unnecessary red tape" governing the government's release of nursing home bed licences so that, eventually, new accredited providers will be able to put beds anywhere they want. At the moment, the system rations beds based on the proportion of people over the age of 70 in any particular region. More providers facing fewer regulations would create "diversity and choice … competition, innovation and responsiveness," the roadmap says. Older people would also pay much more to offset the increasing cost of delivering aged care. Tune recommends increasing fees for those who can afford it and removing current limits on the total amount they can be asked to pay over their lifetimes. Sparrow broadly agrees with the model, though she cautions that the government would still need to play a strong role in rural and remote areas or poor regions where there was no competition and therefore no functioning aged-care marketplace.

For-profit homes' lobbyist Cameron O'Reilly also agrees, and says the for-profit providers will dominate the industry in future because only they, with their access to capital, will be able to do the building job required. Improving care The advocates of deregulation say a deregulated system would also fix problems with care because consumers would only want to live in homes that provide a top-quality service. These homes would thrive at the expense of others. According to O'Reilly: "At the end of the day the biggest thing that will drive improvement of quality will be that you're in the care business, and anything that damages the perception of your quality of care will affect your capacity to run a business into the future."

Eventually, in fact, the Tune reports suggest that high-performing providers could earn the right to withdraw from the regulatory system entirely. If the deregulation of nursing homes sounds similar to what happened in the vocational education system, that's because it is. The deregulation of that system was designed to foster innovation and competition. In reality, the system suffered from a shocking lack of oversight and eventually collapsed under the weight of the rorts. It has now been radically re-regulated. Nursing homes are already much more heavily regulated than private vocational colleges ever were. Asked if there was a danger that aged-care might go down the same path, federal Aged Care Minister Ken Wyatt said he would be "keeping a close eye" on any forthcoming changes. Graeme Samuel, head of Dementia Australia, wants rigorous standards in aged care. Photo: Wayne Taylor Credit:Wayne Taylor



What has to change Graeme Samuel, the former head of the Australian Competition and Consumer Commission, and now national president of lobby group Dementia Australia, says he is "very much in favour" of deregulating the system, saying only "consumer empowerment" would improve it. But he believes much needs to change first. The government's accreditation agency needed "major cultural change". Their "down the line" 44 out of 44 accreditation reports of nursing homes "does not marry up with the information our clients at Dementia Australia give us" and nor with Samuel's personal experience with a family member. "They need to set some standards that are rigorous," he says.

In addition, the Complaints Commissioner must have power to publish the names and locations of nursing homes that had complaints upheld against them "so people can see it and say, 'I'd better avoid that one'". "It's so obvious. When you start doing that, the consumers are empowered and they're only ever empowered by transparency, accountability, which was the fundamental mantra of what we did at ACCC." Choice now was hampered by lack of hard information. "People are bombarded with marketing information, whether it's accurate or not. It's all huff and puff and people put them into a residential facility because of the marketing, and then they find out it's not good and they can't do anything," Samuel says. "The ability to change at that point is limited."

Wyatt acknowledged the problem. "I accept with consumer-directed care, what you have to make available is the information relevant to each facility … we should be transparent ... and I acknowledge that we don't do that with aged care." Professor Joe Ibrahim says the future of aged care is ours to shape. Photo: Jason South Credit:Jason South Some of the only hard information available recently has come from Monash University's Professor Joe Ibrahim, whose team has scoured Coroners' reports to reveal the growing incidence of preventable deaths in nursing homes. But federal funding for his unit at the Monash University department of forensic medicine expired in June this year, and it is now operating on a shoestring and is unable to look at any post-2013 deaths in nursing homes.

"The type of work we do doesn't lend itself to attracting funding," Ibrahim says. "What's astounding is how much money goes into residential aged care, and how little is put aside for research." Whatever happens, Ibrahim says, the future is ours to shape. "Don't get angry with the system – do something to change it. Loading "I look at the future and say whatever we do now as 40, 50, 60-year-olds will come back and pay us in spades. We are designing the system that's going to be looking after us.

"If we are apathetic about that now, we will pay those consequences in our later years."