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THE Australian health and aged care systems are fatally flawed, with no solution in sight.
During past federal election campaigns, including the most recent last year, both sides of the political divide offered only cosmetic tinkering to policies on health and aged care when radical reform is needed. It is also glaringly apparent that election promises have a poor prognosis for survival after the election.
My observations are based on my active involvement in the aged care system in many capacities since the early 1970s, a system I continue to work in today as a clinician.
From the outset, the introduction of the Aged Care Assessment Program was designed to provide the most appropriate types of care for frail, elderly people, including supported accommodation within the aged care system.
However, the result is that today residential aged care houses the sickest and most disabled people in our society. A very high proportion of residents suffer from advanced dementia. Chronic illness impairment, disability and handicap co-exist continuously and must be appropriately addressed.
Despite this, the aged care system is administered outside the health care system. They are like ships that pass in the night but don’t get close to hailing range.
Residential aged care is often plagued by accusations of poor clinical decisions and poor management, particularly around behavioural problems, pain management and palliative care.
Solutions are available to many of these problems — expert assessment and management. I am regularly consulted on such problems, and I visit facilities to address the problem in exactly the same way that I approach a new case in any other setting — interview the patient, the relatives and the care staff. Together we manage to achieve an understanding and reach consensus on most issues, including the use of powerful drugs when everyone accepts that the indications are there and that the benefits outweigh the risks.
Unfortunately, I have yet to meet a geriatric or psychogeriatric colleague on one of these visits.
As in all aspects of medicine, in aged care our primary obligation is towards our individual patient, with the principle of autonomy respected at all times.
I commend the World Medical Association white paper on professionalism — a modern document that reminds us of our obligations to the profession, the health care system and to society in general.
Trying to balance our obligations with the constant pressures of health rationing is particularly challenging. Yet many medical professionals seem to accept rationing when, in many situations, it should be our role to raise questions if patient care is compromised.
However, there is one thing that most of us ration with intent — our time.
At the consultant level we can choose where we practise. While still a full-time public servant I exercised my right of private practice doing home visits, seeing patients in residential facilities in metropolitan Adelaide and in several country centres.
One reason that I am putting off retirement is my certain knowledge that I will not be replaced with a like service. Geriatric evaluation and management teams do not do what I do and they are very selective about who qualifies for their services.
The ageing of the population comes as no surprise. A generation ago, like many people interested in gerontology, I made the pilgrimage to Western Europe and Scandinavia, where similar prosperous countries were already coping with the ageing of their population. What I saw was the high quality of care and rehabilitation that was routinely provided.
Over the years I have made concerted efforts to introduce specialist geriatric services and rehabilitation into our aged care facilities. These efforts have been actively resisted by some government and non-government interests.
It has been put to me more than once by politicians and senior bureaucrats that medicine is too important to be left to doctors. I contend that it is demonstratively much too important to be left to politicians and senior bureaucrats.
The current federal Budget will exaggerate the disparities in the system and will delay necessary reforms of systems and structures.
The government talks of taking hard and courageous decisions for the sake of future generations. This budget has dealt the health and aged care systems a lethal blow. Future generations will have nothing to be grateful for.
Successive governments of both political persuasions have failed to make the real hard and courageous decisions needed to address the ageing of the population and to deal with our current structural problems.
Potentially doctors have the power to be a forceful lobby group for our patients and for our country’s health system.
As an ethical profession we must begin to act as advocates for our patients and the patient populations that we serve.
Dr Ludomyr Mykyta is a consultant geriatrician based in South Australia.
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How do I get into contact with dr mykyta personally
I was a graduate at same year and would like to contact him
Thank you
In response to Anonymous, 2/6/2014.
You have it in one – there is no system. Health care can be organised in various ways, e.g. primary, secondary and tertiary, to which we can add long-term or extended care, which includes aged care and disability services. A true healthcare system provides all elements of health care to the p[opulation of an area or a region, with seamless transition beteween each level.
At present,at State level, we are tied to a workplace, hospitals and their sattelites, and we largely ignore the population that can’t come to us. Primary care and Long-Term care is seen as the province of the Commonwealth.
Surgeons and other interventionalists have to work in hospitals, but practioners who essentially consult can do this anywhere. It is often easier for them to see a patient in other settings than get the patient to their preferred workplace.
I have just returned from a two-day rural visit where I saw patients at home, in hospital, in aged care facilities and at community health centres, predominately to assess for dementia. These patients had seen where it was feasible to see them.
The great Commonwealth- State divide should not continue shape our healthcare service. Considerable savings could be made with re-structuring, and if the Commonwealth realised that it was a funder not a provider. Costs will inevitably continue to rise because needs are rising. Introducing a co-payment by creating a convenient scapoegoat, the rorter of the system, will achieve nothing except harm to the most vulnerable people in our community.
A higher Medicare levy would be a more effective, fairer and easier way to means test and would be a better way of funding the system.
Having spent time as part of an Aged Care Assessment Team I have great sympathy for Dr Mykyta’s view, and I salute his dedication to our elderly folk. However, I cannot help but wonder why Dr Mykyta’s focusses his criticism soley on governments. I worked in an area where there was one geriatrician for an area of about 80,000 square kilometers. Why, because the governmnet would provide funding? No! Because aged care doesn’t attract enough medical practitioners – and those working in the area appear to be well represented by Dr Mykyta. Yes the medical profession should be lobbying for their patients. Hopefully those who are willing lobbyists are willing to spend time rolling up thier sleeves and working in the aged care sector. Dr Mykyta deserved to be able to retire someday.
Not quite sure what the author is getting at, or if he has made any positive suggestions. The fundamental problem I see is that the state governments and Commonwealth government will always palm off costs and responsibilities to each other, between the hospital systems and the Aged Care / primary health care / welfare systems.
Way off topic, but ….
Played hockey with Lu Mykyta in another century
Uni Graduates in the 1960’s
Many of the systems in aged care are similar to a hospital. In addition the residents are older and sicker than in the past as we have many community based services to keep people in their own home for much longer. The logistics of providing care without ready access to medical practitioners onsite is problematic. In particular issues around charting and administering medication. Many people are discharged form hospital at all times of the day and night to return to their residential care facility because of the pressure on the acute hospitals. However continuity of care falls short and new medication can not be administered for prolonged periods. Locums doctors are often used to fill the gaps. Some residents have the majority of their care provided by locums which is unsatisfactory. If RACFs were linked to hospitals or if RACFs employed their own doctors (maybe shared between several RACFs) many of these problems would be solved. In addition less patients would be sent to hospital as a doctor would be available to see them onsite. Certainly change is needed urgently.