Governance in Aged Care: Governing Through Change

Melina Morrison gave the keynote at the Governance in Aged Care: Governing Through Change Conference in Sydney on July 25.

Melina spoke about co-operatives and mutuals as a way of managing your services, exploring the potential for the co-op model to innovate and reform the way aged care is governed and operated, and using this unique model to hold providers accountable for outcomes so older people are cared for with dignity and respect.

Download Melina’s slide pack.

Read Melina’s keynote

Good afternoon.

I begin today by acknowledging the Gadigal people of the Eora Nation as the Traditional Custodians of the lands on which I am speaking today and pay my respects to their Elders past and present. ​I extend that respect to Aboriginal and Torres Strait Islander peoples joining us today.

I am honoured to be here today to be part of the discussion about governance in aged care. I am inspired by your agenda: governing to provide quality care and positive outcomes for older Australians. The least we wish for our loved ones and indeed ourselves.

I would like to thank COTA and the organisers of this conference for the invitation to speak to you today about co-operatives and mutuals as a way of governing through change.

On a personal note, the promotion and advancement of co-operatives and mutuals is my passion. It has occupied 25 years of my working life and defined much of what I believe personally to be one of the most reliable ways to deliver the best outcomes for the people who matter most in any enterprise. In aged care, in my view that is the people who care and the people who are cared for.

I have been given this time with you today to, firstly,

• Explore the potential of the co-operative business model to innovate and reform the way aged care is governed and operated in Australia; and secondly
• to talk about using this model to hold providers accountable for caring for older people with dignity and respect.

I hope to be accountable for covering those topics and invite your candid questions and comments in the time we have for Q&A.

Any talk about co-ops and mutuals should start with explaining what they are; and in the context of this discussion, how they are governed which is linked to how they hold and shape accountability.

On the slide are some facts about co-ops in Australia. Firstly, a bit about the BCCM.

We are the national cross-sector peak body for co-operatives and mutuals, formed in 2013 after a spike in interest in the movement following a UN designated International Year of Co-operatives. Our job is to promote the model in all sectors including care, through advocacy, research and co-operation between co-operatives – the network of our 100 members.

In Australia, there are more than 1800 co-ops and mutuals with combined turnover of more than $43 billion. 8 in 10 Australians is a member of at least one co-op or mutual, and the key sectors are financial services, health insurance, agriculture and motoring. They are also active in care, especially healthcare.

To further lift the lid, these are some co-ops and mutuals you might know through their brands.

Co-ops are everywhere, but they are hiding in plain sight. There’s around 3 million worldwide and 10 per cent of workers globally are either employed by a co-operative or are worker-owners in a co-operative.

100 million households worldwide enjoy access to healthcare through co-ops and mutuals and the model has been confirmed in the health systems of at least 76 countries.

Co-ops are critical to care. The International Labour Conference (ICL) 112th Session which took place in Geneva in June, said in the Conclusions concerning decent work and the care economy, that “public and private enterprises, cooperatives and other Social Solidarity Economy entities, play a role in the provision of quality care, investment in sustainable and modern care infrastructure, and provision of training and employment opportunities.”

Further the United Nations General Assembly proclaimed 2025 as the second International Year of Cooperatives in recognition of their key role in achieving the Sustainable Development Goals (SDGs). The UN’s resolution encourages member states to foster a supportive legal and policy environment for cooperatives, emphasising their importance in various sectors, including care.

The world is pivoting towards inclusive, people centred systems, not least because things are clearly broken but also perhaps because at this time of late-stage capitalism we are yearning for a better world.

This conference is called to address governing aged care through change. That change is clearly announced in the legislated changes from 1 December 2023 that have strengthened provider governance responsibilities concerning the governing body and have placed clear accountability on boards for the quality and safety of aged care.

It is essential that they can work effectively with executives, staff and participants and have the structures in place to govern with the rights of the participant at the centre of care.

Co-operatives are emerging in response to this and other domains of care because they are well-suited to this focus on a rights-based approach that puts the consumer at the centre.

This alignment of aspirations for reforms in aged care that place people at the centre of systems design, and the co-op model which is a people-centred model is what I will focus on today.

Innovation is clearly needed in aged care.

There are aged care supply gaps across 41% of regional and remote Australia and this is projected to increase​. The sustainability of primary healthcare in regional areas is at breaking point​. And, there are significant challenges with workforce attraction and retention and concern that “market based” models are not working.

Aged Care Minister Anika Wells has said she is intent on fostering innovation in the sector so it is more agile and needs-based and there are more options for older Australians to age independently, but to still have access to essential clinical care when they need it.

There can be a lot of talk about innovation with very good intentions. But it can also be easy to glide over innovation and to mistake it for rearranging the furniture.

​Innovation is important to help achieve social outcomes and impact. Technology is often a powerful enabler for innovation; but does not automatically equate with innovation. The critical element is the potential value of the innovation to achieve positive impact in peoples’ lives. Innovations may include new business models, policy practices, behavioural insights, or ways of delivering services that benefit people and communities.​

In half an hour it is challenging to explore the co-op model for its differentiating characteristics, but at its essential core, co-operatives are enterprises owned and controlled by the people that they serve.

Their member-driven nature is one of the differentiating factors of co-operative enterprises. Decisions made in co-operatives are balanced by the pursuit of sustainability, and the needs of members and their communities.

Many organisations in care have members. In a co-op and mutual we emphasis the companion of membership – ownership – because all co-ops and mutuals ensure all users, are common owners of the enterprise, with an equal share of voice typically expressed as one member, one vote.

Co-ops and mutuals provide a legal and governance framework for mutually beneficial co-operation. Co-operatives take many forms such as mutuals and operate in all sectors. They share a set of principles which keep them attuned with their member-driven characterisation.

They are not a company owned by shareholders nor are they an incorporated association, although indeed some start as member associations.

Unique amongst all corporate structures, co-ops ascribe to 7 globally agreed co-operative principles.

Accountability is exercised through active membership, which means reciprocity through participation. Governance is the North Star and steward of transparency and accountability to the users.

Co-ops are built on an agreed definition, these principles and a set of values and ethics.

“A co-operative (is defined as) an autonomous association of persons united voluntarily to meet common economic, social and cultural needs and aspirations through a jointly owned and democratically controlled enterprise.”

The values they ascribe to are – self-help, self-responsibility, solidarity, fairness and democracy. Their ethics are: honesty, openness, social responsibility and caring for others.

Periodically the principles are reviewed and reaffirmed for their relevance by the global peak body, the ICA.

Co-operatives and mutuals are a unique form of organisation for people to collaborate on providing a solution to a shared problem that would be a challenge for them to solve alone. It’s a model particularly relevant in rural, regional and remote Australia, or markets sometimes referred to as ‘thin’ or ‘unprofitable’.

When you empower people in community settings to co-operate on the care they receive or build the capacity of care givers and care workers to design how they provide care, then service quality improves, and the care workforce grows.

I’ll discuss a bit more about how co-ops and mutuals structure governance around accountability to the service users or service providers.

Who owns the enterprise tells us about the motivation of the enterprise and why it is in business in the first instance.

The motivation of owners informs the purpose of the enterprise who are its primary beneficiaries.​

In a co-op, depending on purpose, beneficiaries or members can be the consumers, the workers, a community or group of smaller organisations, or policy holders or mix of these.

Co-op rules ensure appropriate and effective member participation. The segment in this slide that I have pulled out, emphasises the importance of active participation which is a distinguishing feature of a co-operative.

Most governance features are shared across different business models in aged care. In a co-op the fidelity to equality of all users under the active membership structure inculcates a culture of reciprocity and feedback – rights and responsibilities in equal balance.

Members are at the centre of the co-op governance model.

Members are actively engaged in governance – and arguably more meaningfully and effectively engaged than through other representation models like advisory committees – because members also own the enterprise.

The last part of my talk is about the Care Together Program and the policy context for care and support​ in regional and remote areas.

We are all aware that there are systemic barriers that limit opportunities for cross-sector, place-based business model innovation in remote locations​.

These include the capacity or capability of people and smaller organisations in remote areas; systemic barriers that contribute to suboptimal workforce attraction and capability; inconsistent regulation across care and support sectors that stifle sustainable cross-sector innovation; the tyranny of distance and isolation for remote communities; and insufficient housing options for residential care and key workers.  ​

Care Together is a $7 million program funded by the Commonwealth through the DHAC to address these systemic barriers. It is delivered by the Business Council of Co-operatives and Mutuals​​ over 2.5 years. The program concludes in June 2025.

It is a cross sector, place-based program to innovate sustainable business models in social care in priority areas​ – social care may include aged care, disability support, Veteran’s Care, Indigenous controlled services, allied health and primary healthcare (with a focus on place-based, multi-disciplinary teams)​​.

It has been funded as part of a broader policy agenda for the care and support economy to innovate around place-based, harmonised models in regional and remote communities.

We are using co-operative values and principles in each project to demonstrate how diversity of ownership in care and support services can deliver improved outcomes for workers, consumers and communities.​

Projects include a mix of new co-ops or mutuals and growth projects where existing co-ops and mutuals can scale or organisations can convert to a co-op or mutual structure.​

A flagship shared services project is designed to enable smaller organisations to network through a secondary co-operative structure to provide back-office services to support sustainable care delivery in priority areas.​​

Co-ops are not for everyone and they are not for everywhere, but the model is well suited to remote and rural settings and cross sector models.

If you recall the brand logos from before, this is what co-operation at scale could look like in aged care, especially in the context of sharing back-office services and keeping the value in the co-op to benefit its members.

Roadside assistance mutuals for example, provide a logistics network for breakdown services for 8.5m Australians no matter where they live, through a cross-subsidised model to ensure equitable access for all. Members pay the same membership fee whether in Brisbane or Longreach, though clearly it costs more to deliver the same level of service in the more remote location.

Care Together has been designed around a Theory of Change that informs the overarching goal of the program and the three intended outcomes.

The Theory of Change has informed the research, and the monitoring and evaluation components of the program, including the quantitative metrics on outputs and qualitative case studies selected. I do not have time to explore further today, but will just mention, that overarching the theory of change is an impact measurement framework, call mutual value measurement or MVM for short.

MVM is a framework with six dimensions of mutual value designed for co-ops that ensures the contribution to total value creation of elements like member engagement is monitored and measured. Other dimensions are commerciality or sustainability, community engagement, ecosystem and reciprocity, mutual mindset and shaping markets.

Let me now share with you a couple of our 12 projects.

Council of the Ageing (COTA) Australia​

What would it look like if aged care consumers could pool their buying power to access the benefits of economies of scale that you might get typically in a large entity, but still have the independence, choice and control of persons with a personal budget.

We are excited to be working on a project with COTA to co-design with older Australians, and their carers, how they can self-manage their home care packages co-operative –  this reform in home care to enable choice and control and autonomy in a way that has not been possible in aged care​ is transformative and a co-op could be a governance model to facilitate people to work together to get more from the market where they live and wish to age.

This is a staged project to reach agreement and pilot a preferred model in a regional area​.

Moruya Independent Workers​

We are working with a group of more than 20 independent care and support workers​ in NSW to plan the formation of the Eurobodalla Care Co-operative.

Their initial focus is on the NDIS, with plans to extend to other sectors including aged care​. They plan to organise themselves as a co-operative to help manage risks associated with independent contracting and share their skills​ and knowledge with each other. The project responds to the findings from the NDIS review about the large numbers of unregistered workers in the NDIS.

A highly motivated, professional steering committee is driving this project supported by dedicated co-op developers and co-op friendly business advisory services​.

This project is co-sponsored by the Care Together program and the Australian Services Union.​

It has great potential to provide a prototype for other similar worker co-ops across Australia.​

The Summer Foundation is investigating the idea of establishing a Tenant Buyer’s Co-operative in the NDIS​.

Working through a staged approach involving co-design work with younger people with complex care needs living in supported accommodation​, they are exploring enabling choice and control including where they live, and with whom​ they live.

This project seeks to find innovative alternatives to younger people living in aged care homes and traditional group homes.​

The tenant population for the Summer Foundation is people with NDIS approved plans who rely on 24/7 supports to enable their independence.​

The Aged Care Royal Commission made specific recommendations about making sure that appropriate alternatives were in place for younger people with disabilities having to resort to living in aged care homes.​

The project design is unique in that Care Together is educating the Summer Foundation’s co-design staff about co-ops and the kinds of issues that need to be considered in forming a tenants co-op where the members pool part of their approved NDIS plan to enable the sharing of 24/7 support workers.​

You may see some synergies with the COTA project.​

The project is at the stage where the indication is that the participants involved in the co-design exercise want to proceed to form the co-op.​

Wagin WA

My last example is situated in the small rural town of Wagin, WA, about 4.5 hours drive from Perth, a region with a strong history of co-operation ​being the wheatbelt and home to many of the farming members of Australia’s largest co-operative, an agricultural business that exports 50% of Australia’s grain crop – CBH Group.

The impetus for Co-operative Care Wagin came from a community led Village Hub with a focus on social support for healthy aging for locals. A small group of Wagin locals have driven the project with a goal to connect people who need care with those who provide it​ across the region.

This is a very local “home grown” project that is inspired by concerned long term residents who know that there are many people who need care and support in their communities who are not getting it.​

The potential of this project, in addition to enabling improved care and support outcomes for the people of Wagin, is that a co-operative model may have potential to network other small rural towns.​

There are other models similar to what the residents in Wagin are trying to achieve. However, usually other approaches rely on having an Approved Provider, not always locally based, and a privately owned platform to connect the workers to the people who need care.​

The Wagin project will certainly be one of the use cases included in the co-design project around forming a National Shared Services Co-op for care and support sectors.​

I would love to spend more time on examples such as the group of aged care homes across Murrumbigee starting to explore a shared services model to support the sustainability of their independent care facilities, and the multidisciplinary health hub model being supported to form in Glenn Innes under the auspices of the Hunter and New England Primary Health Network.

Fortunately, our program director, Gillian McFee is in the room today to help me take questions on any of the projects I have described.

What can we expect from Care Together in a year’s time?

In Australia, compared to other countries, we are behind in utilising the co-operative legal and business model in care and support sectors and this is a key focus of our activities through the program.

We are also tapping into the worldwide co-operative network to learn from and accelerate adoption of piloted and tested co-op models such as the Elevate Co-operative in the US.

We are excited to be bringing the ICA Group which is developing Elevate, to Australia in November to assist with our shared services co-op project including a series of co-design workshops with selected participants to help inform the development of a user-tested digitally enabled prototype for shared services.

In closing, I will return to the conference agenda: we are concerned today with the conversation about governing to provide quality care and positive outcomes for older Australians.

I would like to end with this quote by Robert Fitzgerald, Age Discrimination Commissioner which speaks to the connection between co-ops and this ambition.

“I believe co-operative and mutual enterprises in human services can increase diversity and choice at a time when there is a weakening of community trust in the quality and safety of services provided to vulnerable people. This is especially so in disability, aged care and in services for protecting children and young people.”

We believe the co-op model provides choice for aged care providers who want to improve sustainability and impact through co-operation rather than in competition.

If I can share an invitation for those present to further explore the model and program I have discussed today, we would be delighted to have you join us for our regular Community of Practice webinars, which you can sign up to via the website – which also has a wealth of resources and information, case studies and news.

I believe we have some time for Q&A and thank you again for this opportunity to speak today.