A complete audit of nursing home residents?

In September 1992, I wrote an article for a specialty publication criticizing the Ministry of Health and Welfare's paper entitled "Guiding and Auditing Welfare Facilities for the Elderly. The ministry document included a heading called "Policy Formulation for Individual Entitlements," to become mandatory for all residents of public nursing homes. In my article I pointed out that it is dangerous if the government records, evaluates, and plans the lives of individuals.

The article included the following passage: "It is possible to audit the flow of money by collating various ledgers and receipts. Auditing people's lives with documents, however, is not a practical idea. [What they are planning] is to apply the concept of balance sheets (policy on individual entitlements, minutes of entitlement evaluation meetings) onto dossiers of people's lives (i.e., case records), in order to audit whether results show a profit or loss (in terms of the effectiveness of rehabilitation, effectiveness of ADL, intelligence evaluation scales)."

Now I must revise this statement. It is NOT possible to determine the crucial flow of money under audits carried out according to Ministry of Health and Welfare guidelines. And I would like to add that those in most need of "Policy Formulation for Individual Entitlements" are none other than the civil servants themselves.

A royal inspection, complete with courtier

In 1993, when the critique was published, the public nursing home at which I am employed was, by "coincidence," subjected to an audit by the Ministry of Health and Welfare (under normal circumstances, the prefectural authorities come for an audit every year). You do not know how worrying it can be to have every corner of your ledgers examined unless you've experienced it. Unlike a certain welfare group currently in trouble for collusion with ministry officials, there was nothing to fear at the home I work at, but even a slight mistake in office procedures would have led to disaster.

In any event, the ministerial audit went without a hitch. But my attention was on something other than the audit itself.

During the two-day audits, an official from the prefectural government accompanied the ministry auditor. An official car provided by the prefectural government is used for transportation. What I found strange is that throughout the audit, from morning till evening, the prefectural official spent the entire day waiting in the car (buses and taxis are available in the vicinity of the home). Meanwhile, I have to make do with a constrained budget and stretch my personnel resources to the limit. On the ground we are "busy enough to wish the cat could help" (as the saying goes), bathing our residents, taking care of their toilet, and feeding everyone. All that time, the prefectural official in charge of driving does nothing all day except wait for the official from the Ministry of Health and Welfare. Prefectural taxes are being used just for waiting. It's not as if a foreign dignitary is visiting -- is a civil servant from the national government that much a VIP?

I think this sort of thing, like wining and dining, amounts to a gift of complimentary services between government officials. I cannot help but think that an extension of this attitude results in the use of food budgets for paid entertainment. How frustrating it was to be instructed on the correct use of taxes (the budget for the nursing home) by people for whom such practices are the norm.

Thwarting visits from officials on the ground

1993. In this year, local governments across the nation were formulating and announcing regional welfare plans for the elderly, tailored to local characteristics, and based on the Gold Plan, said to have been promoted by Administrative Vice Minister Okamitsu Nobuharu, who was arrested on suspicion of having taken bribes. The new welfare plans were better compared to the earlier plans, because they included detailed targets and deadlines, such as nursing homes and day-care centers to be built by 1999, or the number of staff to be hired. "The Ministry is serious this time." This was the impression, and people on the ground worked with heightened intensity.

At the time, I was assigned as associate editor of a publication specializing in welfare for the elderly. Together with staff from public nursing homes, I devised a feature along the lines of "working staff -- not some prominent person -- visiting and discussing their vision with ministry officials, who work so hard to improve welfare for us citizens." The publication's management negotiated with the ministry, and everything was ready. Pages were reserved, staff chosen for the visit, and even the schedule was finalized. Yet immediately prior to the interview, the ministry canceled.

Apparently, when the issue reached the higher echelons of the ministry, it was shelved out of "a danger of causing misunderstandings." I can only think that the Ministry of Health and Welfare wants to exist on a higher plane than mere mortals. They come to audit, clad in the armor of authority, but they don't even allow visits by staff on the ground.

Authoritarianism instills helplessness in citizens

I admit that this episode is a personal and trivial matter. But for me, an official of a nursing home, it was a significant event. And that is, in fact, the crux of the issue. Citizens accumulate numerous experiences of such small incidents, and start to believe they are powerless -- and consequently become convinced that they will suffer if they give their straight opinion. In the end they give up even trying. I submit that herein lie the origins of the breeding ground for momentous crimes such as the tainted blood products scandal. It is because those in authority are aware of the imposing power of their authority that they do such things as hiding evidence the way they did, treating, in effect, patients and citizens with contempt.

Guilt by association

It should be said that this culture of snubbing citizens is not limited to bureaucrats of the Ministry of Health and Welfare. A public nursing home is run on public funds (taxes). My salary comes from those funds. Ministry officials and the staff of a public nursing home can thus be said to be, from a citizen's standpoint, in the same position.

I sometimes think that the staff of public nursing homes, myself included, have a similarly contemptuous attitude toward residents. In other words, clad in the armor of the closed nature of residential homes and a false idea of perfection, we force our good intentions on the residents and do not criticize ourselves. I do, of course, try to be as self-recriminating as possible.

It would seem, however, from the permeation of such an attitude to the very ends of the tendrils of the welfare apparatus that it could well be because each and every worker in the welfare industry is tightly tied down by the absolute authority of the ministry. In reality, under the current system, the principle job of the regional governments is to constantly gauge the ministry's disposition. To be quite honest, as someone who daily struggles to make ends meet under a tight budget, I sometimes let my fancy envisage a thick connection with the ministry. If the official on the other end (a ministry official) had been so inclined, I myself could have ended up a perpetrator.

Empowerment for citizens

Ever since the recent corruption scandal in the Ministry of Health and Welfare became public, there have been calls for stricter moral standards among civil servants. But it is just too ridiculous if those calls come from politicians, who are cut from the same cloth. I can't help but think that, no matter how much you call for stricter ethics, all that happens is that straight arrows become even more rigid than heretofore and premeditated criminals just become more wily.

In conclusion, I believe empowerment of citizens is essential in changing the current situation of welfare administration. There have been calls for public disclosure of information. For example, even when determining bids for individual nursing contracts, it is necessary to have the right to know what processes determined the decision and with whom the responsibility lies, i.e., who made the decision according to what criteria. And each and every citizen must be guaranteed the right to voice objections. The true value of disclosure lies in whether or not citizens can exert external pressure on the administration. Whether it be the national government or a worker dispatched by a public nursing home, each and every citizen must be able to protest deplorable occurrences that affect him or her, to express what he or she wants to have happen, and to investigate the outcome. Collectively, all this will lead to changes in welfare, as well as society.

Moreover, only when the transparency of the approval process is guaranteed can I live free of the fear of being told, "We trash requests from a facility run by someone who writes stuff like this."

12/30/96