Ludomyr Mykyta: Aged failings

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.