AGED care is not a unitary concept. However we define “aged”, we are talking about a huge number of extremely diverse people.
It is ridiculous to believe that aged care can be put under one umbrella or a single system of care, whose mission, codes of ethics, objectives, strategies and operational programs, standards etc, can be lifted straight out of a management manual and applied to all elements equally. All such systems claim to respect the autonomy and freedom of choice of the individual. Fair and equal access to needed health care does not seem to be an equally demanding ethical principle.
This heavy end of aged care (nursing homes in the old language) is a regular source of horror stories that hit the national headlines in all forms of media. There are terrible stories of neglect, abuse, and pharmacological mistreatment. A regular headline provider has been the misuse of psychotropic medication in nursing homes. The medical profession’s major contribution has been to fan the flames of righteous indignation with statistical analyses worthy of a PhD. Another recent headline has shown the high incidence of premature death among nursing home residents (an interesting concept when applied to people in the palliative phase of their lives), with helpful advice about how this should be remedied.
The Australian Senate is currently holding an enquiry into Oakden nursing home, which is a much-studied example of neglect, abuse and mistreatment. Not only was it much studied, Oakden had also been audited and accredited by the Australian Aged Care Quality Agency for the standard 3-year period in 2013 and 2016, meeting all of the 44 outcomes required.
In Australia, we have progressively divorced aged care from mainstream health care and turned it into a business, managed and run as such. As a result, aged care facilities are not staffed, equipped or managed to meet the health care needs of the people that they supposedly care for. This is unfettered managerialism, but good for business.
Oakden was identified as an Older Persons Mental Health Service, a highly specialist health service. A large sign with the South Australian government logo identified it as “Aged Mental Health Care Service” to emphasise this fact. Clinicians answerable to SA Mental Health Services for the Elderly and general practitioners provided specialist and general medical services to the residents.
The Oakden disaster exposed the schism within the health care system. What we perceive as the Australian health care system is only the elements that are controlled and managed by the states. Simply put, that is tertiary care and the elements of secondary care that emanate out of the hospitals. Much of secondary care and all primary care is controlled and managed by the Commonwealth.
In Western societies such as Australia, this is the era of chronic illness and the ageing population. Primary care is the base of the health care pyramid. It is the principal provider of continuing and long term care for people of all ages and regulates the flow into the higher levels.
What is the purpose and role of high-level residential aged care? One way of determining the purpose is to examine who occupies it. The answer that I see when I visit these places is that they accommodate the sickest and most disabled people in our community. Almost all of them have at least moderately severe dementia. Aged Care Assessment Team evaluations prove beyond doubt that these residents need intensive long term and continuing expert health care, not just accommodation plus personal care.
When a medical practitioner enters a doctor–patient relationship, the practitioner accepts the ethical obligations that underlie that relationship. When a facility, a specialist health unit or a specialist service are involved, that whole service has the same obligations as the individual practitioner.
For all its associations with the mental health services, Oakden was a high-level care residential facility, never a health unit. Had it been classified as a health unit, it would never have survived accreditation, and we would not be reading about it now.
Had it been a health care unit, what happened at Oakden would have been seen as a gross failure of clinical responsibility. Any competent practitioner would have been expected to recognise elder abuse and maltreatment happening to their patient and to take immediate corrective action through the system, the clinical hierarchy.
When the dust settles, some heads will roll, and new standards couched in flowery language will be developed, but there will be no fundamental change in the way that the separated health and aged care systems operate. It would be too much to hope that the Commonwealth could recognise that while it is the rightful and obvious funder of the health care system, it is a hopelessly incompetent provider.
Dr Ludomyr Mykyta, AM, is a consultant geriatrician based in South Australia.
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