Aged care: a rural GP’s view

ONE of new Prime Minister Scott Morrison’s first policy announcements came on 16 September, foreshadowing an Aged Care Royal Commission.

A related announcement was also made by the Minister for Senior Australians and Aged Care Ken Wyatt, which listed the foundations upon which the Royal Commission’s Terms of Reference (TOR) would be built:

• the quality of care provided to older Australians, and the extent of substandard care;
• the challenge of providing care to Australians with disabilities living in residential aged care, particularly younger people with disabilities;
• the challenge of supporting the increasing number of Australians [with] dementia and addressing their care needs as they age;
• the future challenges and opportunities for delivering aged care services in the context of changing demographics, including in remote, rural and regional Australia; and
• other matters that the Royal Commission considers necessary.

These foundations are open-ended; therefore, awaiting detailed TORs won’t change much. The last of the five points is a blank canvas for the Royal Commission to look at whatever it likes; I think this broad approach is warranted in such a complex, important sector within our society.

More critical than the TORs are who Prime Minister Morrison appoints to lead the Royal Commission and how well resourced the process shall be.

Some people may argue that the Prime Minister is playing politics, citing that there have been many investigations into the aged care sector, some of them ongoing. A good summary of such investigations appeared in The Conversation recently.

By quoting the following statistics during his speech, the Prime Minister clearly knew that he would ring alarms:

• a 177% increase in services with serious risk identified in the past year; and
• a 292% increase in services with significant non-compliance, with one service per month being shut down by the Department of Health.

There was also a record number of complaints (5779) received by the Aged Care Complaints Commissioner in 2017–18.

We all know not to take these figures at face value, for definitions of risk and non-compliance change and may be subjective. Complaints may have become easier to lodge and perhaps even been encouraged in our society that appears more and more obsessed with surveys and feedback.

However, in fairness to the Prime Minister, there is a general feeling that the aged care sector is floundering (even Bill Shorten agreed) and hitherto investigators have not enjoyed the powers or breadth that this Royal Commission offers. There is no reason why the Royal Commissioner cannot draw on the findings of the other investigations when formulating recommendations.

A precis of key stakeholder concerns is timely.

Residents and their families

It would be sad if the Royal Commission became a glorified TV current affairs show and only investigated abuse, theft and violence. While clearly such extremes cannot be ignored, they are thankfully rare and should not distract from the larger, systemic issues.

Residents and their families encounter many challenges, in my experience. The most serious I have seen are:

• inappropriate use by residential aged care facilities (RACFs) of the Aged Care Funding Instrument in order to select residents who will bring the most money for the least work;
• selection of residents who are most willing to pay for private services outright or as “value adds” to their basic packages;
• the complexities of means testing can be very unfair, resulting in some families needing to sell their home to place a loved one in care, whereas other families may not simply as a result of clever accounting;
• in rural and remote areas there is often a RACF monopoly, which could potentially result in preferential placements for those with connections to the facility managers;
• younger persons are often unable to access RACFs that meet their needs, and in fact sometimes cannot access them at all; and
• nutrition standards for residents which are below acceptable levels, with frozen meals, inadequate portions and lack of staff to assist feeding.

Nurses and carers employed by RACFs

“Exhausted” and “stressed” are the first two words that come to mind.

“Ratios” is the buzzword. There is no way that the Royal Commission will be able to avoid this in the course of its work. In all facilities I know, the staff would like to do more but there are simply not enough hands on deck. To improve standards, there needs to be more than just better formulae to calculate staff numbers; it needs to be backed up by funding.

An extension of this is that in some places there appears to have been a proliferation of administration workers within facilities, often at salaries well above those of the carers. If funding for more staff and better ratios eventuates, precautions need to be put in place to ensure facilities don’t divert these funds away from personal care of the residents towards administrative tasks.

Patients in RACFs are getting heavier, which means physically they are more difficult to look after. Moreover, there are additional increased difficulties due to the ageing population. Given better home care services are now in place – a wonderful thing in itself – patients admitted to RACFs are now sicker than previously.

General practitioners

GPs are the next most important providers of health care in aged care facilities, after the internally employed nurses and care staff. This gives us an excellent view of the inside, while also maintaining an arm’s length to make some impartial suggestions.

The dwindling number of GPs who provide care to RACFs is noteworthy – anecdotally, the figure has been rumoured to be less than 25%. That so many GPs abandon the continuity of care of their patients as soon as RACFs become involved is an important topic for the Royal Commission. It raises questions about red tape and the adequacy of the Medicare Benefits Schedule.

Frustrations that GPs encounter in RACFs on a daily basis include (but are certainly not limited to):

• reliance and inadequacy of five enhanced primary care visits per year per patient to deliver allied health care;
• duplication of note keeping, as RACFs want GPs’ notes but they need to also keep their own set at their office in case of audit etc;
• despite all the promises made, GPs still need to do both medication charts and scripts for residents, over and over, every few months;
• communication with GPs is inefficient, especially after hours when patients are often sent to the emergency department rather than a simple telephone call made to the GP;
• red tape for GPs to be “credentialled” to visit the RACF — a GP that was good enough for the patient in the community is suddenly not good enough in the RACF;
• telemedicine is underutilised;
• transport to specialists and services is too hard to arrange, with ambulance services often not interested, families unavailable and the RACF denying responsibility;
• clinical standards vary widely (eg, injectable drugs, dressings); and
• nursing staff often do not have time to assist in the assessment and management of patients.

Some of Australia’s most vulnerable patients and workers are to be found in the aged care sector. While it shall undoubtedly expose many problems, tragedies and even crimes, I see the Aged Care Royal Commission as an important, positive step towards giving this sector the respect and attention it deserves.

Dr Aniello Iannuzzi, FACRRM, FRACGP, FARGP, FAICD, is a GP practising in Coonabarabran, NSW, and a clinical associate professor at the University of Sydney.

The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.