Following on from his recent article, Ludomyr Mykyta reviews the Royal Commission into Aged Care Quality and Safety so far.

IT IS beginning to look like the Royal Commission into Aged Care is heading the same way as other recent high-level reviews of elements of aged care: accept the status quo as a given, and tweak the process with tighter accreditation and increased contact hours with trained staff.

Peak bodies such as the Australian and New Zealand Society for Geriatric Medicine — an organisation of which I am a co-founder and past president — tacitly accept the structures and systems as appropriate. There is a failure, or a deliberate refusal, to see the elephants in the room.

The first of these elephants is that high-level residential care is a level of healthcare, not an accommodation option. As I have said before:

“Aged care is not a unitary entity. It has two distinct elements: accommodation and community support, and long-term health care. We entrust it to the accommodation sector when it is clearly the responsibility of the health care system.”

One wonders when, how, and why the Minister for Aged Care (currently Hon Ken Wyatt, MP) was separated from the Minister of Health (currently Hon Greg Hunt, MP). This separation reflects the disconnect between aged care and the sector to which we have entrusted it.

The standards of care that must be met in residential aged care facilities are set by the Australian Council on Healthcare Standards. Enforcement of these standards is impossible when the facilities are not within the health sector. It is instructive to observe that non-government organisations and businesses run private hospitals and meet relevant standards.

Also, under the current arrangements it is difficult — if not impossible — to achieve proper medical attention for residents in aged care facilities for many reasons, including the lack of incentives for general practitioners to take a leading role in the management of residents. I can think of several ways that this could be achieved, but the Commonwealth — as the funder of primary health care — is out of its depth, as I will now explain further.

The larger elephant in the room is the Commonwealth. My Aged Care is nothing short of appalling. It is poorly conceived and even more poorly managed. The designers and managers have no understanding of the issues that confront the “client” and the client’s partner and family. Navigating My Aged Care is a mighty challenge — even for those family members who are not suffering from cognitive decline.

Anyone with experience dealing with people suffering from dementia will understand that it is often very difficult to persuade these people, particularly as they progressively lose their insight (the capacity to understand their current situation), to agree to accept assistance, and even to be assessed by someone like me, with expertise. They know what they want and don’t want, but they may lose understanding of what they need. Often, there is reluctant acceptance during a time of crisis, but by this time, the service sought is overdue.

According to the latest Home Care Packages Report the waiting time for people who have been assessed by Aged Care Assessment Teams as being qualified for a package is over 12 months. I wonder how many people die while waiting for their Level 3 or 4 aged care package to commence?

I am focusing on aged care. However, everything that I am saying applies equally to the whole Australian healthcare system. The States do it better than the Commonwealth. It is appropriate that the Commonwealth is the funder and has the responsibility to distribute funds equitably through the States, but my belief is that the Commonwealth has, up until now, been an incompetent provider.

It does not seem to me that the Royal Commission into Aged Care Quality and Safety has come close to tackling these bigger issues.

Dr Ludomyr Mykyta AM is a consultant geriatrician based in South Australia.

 

 

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 InSight+ unless so stated.


Poll

Aged care in Australia should be rebuilt from the ground up
  • Strongly agree (70%, 187 Votes)
  • Agree (19%, 51 Votes)
  • Disagree (6%, 15 Votes)
  • Neutral (4%, 10 Votes)
  • Strongly disagree (2%, 6 Votes)

Total Voters: 269

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12 thoughts on “Tweaking the untweakable: aged care

  1. Anonymous says:

    Dr Mykyta writes that “The standards of care that must be met in residential aged care facilities are set by the Australian Council on Healthcare Standards”. This is inaccurate. The current Accreditation Standards are set out in the Quality of Care Principles 2014 which were formulated under the Aged Care Act 1997. The Aged Care Quality and Safety Commission accredits residential aged care services against the Standards, and monitors their compliance with the Standards.

  2. A/Prof Joachim Sturmberg says:

    I agree, the system is broken. Broken systems need to be redesigned (Sturmberg – Health System Redesign, https://link.springer.com/book/10.1007/978-3-319-64605-3). The redesign needs to focus on “the needs and aspirations of the resident and his/her family”, and the accountability systems need to reflect the “achievements of having met their needs and aspirations”.

    One would hope that one of the recommendations coming out of the Commission will be that residential aged care facilities have to focus in all their activities on outcomes rather than the prevailing focus on processes. Or, to put in Peter Drucker’s term address the difference between “doing things right ” and “doing the right things”.

  3. Lu Mykyta says:

    I am too subtle. What I am trying to suggest is that the standards that should apply to this level of health care should be the Standards set by the Australian Council on Healthcare Standards for health units. The standards referred to above are not adequate,

  4. John Ward, Geriatrician says:

    Lu, It was good to read your thoughts.
    The fundamental problem with residential aged care is that it is expected to serve 7 roles:
    . a home for some people
    . a high level nursing/medical facility for some of the most complex patients in our healthcare system
    . a specialist dementia unit dealing with a full range of challenging behaviours
    . a unit for the care of older people with chronic psychiatric problems
    . a hospice for the dying
    . a long stay facility for younger people with traumatic brain injury and other problems for whom there is no other accommodation
    . a rehabilitation unit.

    The other glaring deficiency in our aged care system is the lack of any planning or resources for the assessment and management of dementia in the community. No government has accepted responsibility for this.

  5. Anonymous says:

    Also, I think we need a redesigned set up where we have experienced Australian trained and registered nurses on all floors of nursing homes. They need to be able to speak clearly, and understand what is required of them .
    Before I ‘m called to visit a nursing home patient , an experienced RN has to inform me of what the problem is: What has been done for it – I don’t want untrained personal carers ordering visits. I think that if we started charging patients $175 for a call out fee , the frivolous visits would suddenly cease.
    Also, I would like a separate,dedicated examination room in the facility where, before I attend at an agreed time ,patients would be there waiting ,with a registered ,trained nurse or a family member

  6. Dr J Michael Wynne (retired surgeon) says:

    I share your views about the reluctance of the Royal Commission to address elephants in the room. Governments in trouble select those they can trust. We need to understand that the background of both commissioners and their careers in dealings with government will make elephants very challenging for them. While anyone can make a submission the Royal Commission decides whom it will call as witnesses.

    I have watched the US aged care system and then our aged care system with concern over the last 25 years. I have watched it steadily and predictably destroy itself and have protested by helping draft submissions to inquiries.

    My primary concern is the provision of care through a process created within a pattern of thinking, neoliberalism, that came to dominate Western society in the 1980s. Its founding thinkers promoted selfishness as a virtue and central to our actions. They condemned altruism, one claiming it was a disease imposed on us by society. Social responsibility and social justice were also condemned. The only road to freedom was through markets. A hidden hand ensured they would correct any problems provided they were not interfered with (ie regulated).

    The philosophy condemned any restraint on the individual and on markets including by society (the collective) and its values, the values on which care depends. Society was pushed aside and marginalised.

    Neoliberal policies have been implemented through managerialism – a process that requires no expertise in the sector but claims the right to manage those who do because it has superior outside universally valid expertise. It adopts strategies that bind those it manages to the organisation’s thinking and primary objectives – which are seldom care.

    While many might now dissociate themselves from this thinking, the system and its structures were set up in this way in 1997. Driven by competition and efficiency, there was no provision for vulnerability, for caring relationships to form or for the expression of our values. Its dysfunction and failure is not unexpected. This is a failure of a managerialist policy that did not understand society or care and Dr Mykyta’s concerns about the system are a part of that.

    The organisation that I am associated with seeks structural change and at a meeting with the minister to discuss terms of reference for the Royal Commission we were assured that it would be considered within them.

    Our group was invited to give evidence and I offered to do so. My statement provided evidence and argument that the system was deeply flawed. It provided data and explained how poor the staffing and regulation really were and why.

    Like the banks and the many other market failures in vulnerable sectors including human services, this lay with the thinking within which these sectors were all structured. We intimated the sort of structural changes needed to make this market work differently without disrupting services.

    This was intended to be challenging and to open up debate and discussion on these long neglected elephants. It seems it was too challenging and after a brief inquisitorial telephone discussion our invitation was withdrawn.

  7. Dr. Simon perrin says:

    What insightful commentary Dr. Wynne.
    Inadequate staffing and funding are the issues driven by some right wing ideology of “the market will fix”

  8. Neil Donovan says:

    Thanks so much for these insights. Just to look at this another way, what role do the RACF’s owners have in this debate. ?
    Yes the government is the funder of Primary Care but BUPA and other owners seem to take no responsibility for constantly cutting corners , compromising care and sustaining sanctions. They are the real profiteers. Perhaps if we looked to shareholders and church goers to speak up / take action and fund Primary care from their profits or assets we may gat more traction.
    I don’t know you go about that. Public shaming and GP’s withdrawing services. ?

  9. Donald ROSE says:

    There is a shrinking cohort of dedicated GPs providing the bulk of medical services to an ever increasing number of medically complex aged care residents. Their resources are limited to their own experience and the experience of their GP colleagues and an occasional visit to the local hospital which usually concentrates on putting an advanced care directive in place to allow them to do little and discharge the resident back to the RACF as a matter of urgency. Many hospital specialists believe the elderly are not their problem, should not occupy precious hospital beds and belong somewhere else. The trouble is somewhere else has none of the backup they enjoy ia a public hospital. This is true silo care. RACFs don’t help by having differing management structures, differing staffing levels, differing medication systems, differing after hours policies and the list goes on. It needs a shake up for sure. But with a collapsing public health system I am not sure calling it a health facility will help.

  10. Dorothy Stone says:

    Aged care is a complex as the individuals who utilise the service and those providing the service. The key issue for many a year is that the Commonwealth has be the law maker judge and jury in conjunction with being the business developer. Yes major players seek to profit from their activities and why not. Ask yourself who authorises their activities by endorsing the approved provider label that same institution. Geriatricians and GP also do not provide service pro bono nor do they seek to challenge providers if they identify inappropriate service delivery. We as a society allow issues to be poorly managed and absolve our respondibilities. Aged care cannot and never could be all things to everyone, the health sector is not interested in aged individuals they do not attract WEIS funding at levels which optimise funding for hospitals. Aged care as it stands today is a sad indictment to us as a society. But can I say there is some amazing work undertaken by amazing individuals in residential aged care. A number of whom I have the privilege to call associates

  11. Anonymous says:

    A little background. Not only doesn’t ACHS set Aged Care standards, it doesn’t set any standards at all. ACHS administers hospital accreditation standards (NSQHS) set by the Australian Commission on Safety and Quality in Healthcare. And for reference the Groves Report into Oakden was critical of ACHS for their (then) recent accreditation of the Clements Wing (u 65). Groves didn’t mention aged care accreditation at all. No Nevertheless the Quality Agency also faced criticism for its role too.

    Aged Care was for some years part of the Social Services portfolio before being returned to the Health Portfolio in 2015. Ken Wyatt is a Minister in the Health Portfolio. As well as being Aged Care Minister he is Minister for Indigenous Health. There is no disconnect between Hunt and Wyatt. In fact their offices are next door!

    I would welcome your comments on the role doctors played at Oakden. They were in there day in and day out prescribing and treating. No comment on them??

    I encourage you to research your comments more thoroughly

  12. Dr J Michael Wynne says:

    All interesting comments. The problem is that its not working for far too many but we don’t know how many and each person and situation is different. This has gone on for 20 years. The argument is that Neoliberalism with its lack of morality and managerialism with its focus on processes cannot address this from the board room. Nor can a regulator that drops by once a year.

    The suggestion is that expertise, empathy and regulation needs to be local and responsive to each individual and be based on the caring relationships that these two belief systems make it so difficult to develop. This brings the many different eyes and perspective together at the place where they are needed. Some things belong in the community and this seems to be one. We need a context where people are motivated and enjoy being.

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