This article is part of a monthly series from members of the GPs Down Under (GPDU) Facebook group, a not-for-profit GP community-led group with over 6000 members, that is based on GP-led learning, peer support and GP advocacy.
THE Royal Commission into Aged Care Quality and Safety will undoubtedly unearth shocking and unacceptable individual outcomes for residents of aged care facilities. I suspect, sadly, that they will come as no revelation to GPs who visit or have visited their patients in residential aged care facilities (RACFs).
It must be recognised that these individual outcomes are the by-product of a system that, in its current form, incentivises profit and cost-cutting above people. Too often, elderly Australians are not given the care that everybody deserves as they enter their golden years.
The role of GPs in aged care is a vital one and yet attracting and sustaining a skilled medical workforce to serve patients is increasingly difficult, in view of a number of barriers that have been set up through years of government neglect:
- the constant and non-remunerated duty of being on-call 24 hours a day for patients;
- facilities that are rightfully intended to be the patient’s home, but unfortunately are neither equipped nor staffed to provide modern medical care;
- increasing administrative requirements that serve bureaucrats, not patients; and
- a system that does not support the expressed wishes of many Australians to receive palliative care in their own home.
Through my individual experience caring for my patients who reside in RACFs, I have considered how the system could be improved to encourage specialist GPs and other health care providers to take up the care of patients in nursing homes.
This does not need to be complicated. It does not need yet another taskforce to divert funding intended for the coalface. It requires commitment and recognition that our elderly Australians deserve high quality care affording them dignity and respect.
I present for consideration a list of changes that I believe could be implemented to achieve positive and sustainable change for Australians who reside in aged care facilities.
- GPs should be financially incentivised to service RACFs. The current fee-for-service model that underwrites GP attendance is clearly unfit for purpose. The recent Medicare Benefit Schedule changes, trumpeted by the government, are manifestly inadequate. I would suggest that GPs be offered an hourly salary of the equivalent of a staff specialist in the public hospital system, including for non-clinical tasks such as case conferencing and clinical governance, and that GPs who provide health care for their patients as necessary be paid an appropriate call-out fee for this service, including a retainer for on-call services and loading for weekend and after-hours attendances.
- Mandatory nurse-to-resident ratios should be implemented. The public hospital system has been moving towards mandated nurse-to-patient ratios and this is now in legislation in Queensland. Having worked as a doctor in inpatient units and RACFs, the physical care needs of people in these settings are often similar, yet nurses in RACFs are often overwhelmed with the sheer number of residents they are expected to care for on a day-to-day basis, let alone if a resident becomes medically unwell.
- RACFs should hold a stock of emergency medications, such as antibiotics and opioids that can be given to patients with a doctor’s written or telephone order, to manage issues that arise after hours. If a resident develops, for example, lower limb cellulitis, currently a GP would attend, write a drug order, write a separate prescription, and this would then be dispensed and delivered from a local pharmacy. This convoluted process often results in the resident’s treatment being delayed, sometimes until the next day. I wonder if the CEO of an aged care organisation would be happy to wait until the next day to start urgent medication, or wait until the next day to receive an opioid for severe pain.
- There should be a standardised medication chart that a contracted pharmacist completes and fulfils based on the GP’s prescriptions, rather than supplying regular medications through the Pharmaceutical Benefits Scheme and on an individual prescription basis. This would replace the current system of each RACF having a different medication chart and the GP having to spend hours of unpaid time represcribing medications for their residents.
- Resident diets must be individualised and supervised by a dietitian and speech pathologist, with oversight from the patient’s usual GP, taking into consideration the patient’s expressed wishes and quality of life considerations.
- The RACF must take responsibility for providing patients with access to physiotherapy, occupational therapy, speech pathology, podiatry, clinical psychology and optometry, rather than the current haphazard approach of scattered allied health availability with considerable interfacility variability. Having a true multidisciplinary approach to the care of residents would allow for coordination of care, regular case conferences and shared involvement in patient care and decision making.
- RACFs should have a standardised kit of medical equipment, such as a basic diagnostic set, electrocardiogram machine, local anaesthetic and suture material, biopsy sets, and a room with a printer and wireless access to a network to allow visiting practitioners to provide residents with a service that is as close as possible to what they could expect from visiting a GP in their surgery, including their right to patient confidentiality.
- An accreditor must conduct spot inspections of RACFs and severely punish companies who do not provide these services adequately and in so doing neglect the care of vulnerable elderly people. Unless there is a swift, direct financial effect on the responsible parties, there is an incentive to maintain the current unacceptable status quo. Such penalties could include fines of several hundred thousand dollars or even criminal charges levied against those responsible. This may seem extreme, but the reality is that a RACF, and by extension the organisation that runs it, is entrusted with the care of patients who are frail, vulnerable and often do not have a voice. Providing care that is substandard for profit, while people suffer, is to abuse this trust. Any punishment should both reflect the severity of this abuse and also act as a significant deterrent for companies who may attempt to profit and cut costs while endangering the welfare of those they have undertaken to protect.
This system would provide care more like the pamphlets and advertisements for aged care facilities and less like the cases that have been uncovered in the media recently (here, here and here). The true mark of a quality aged care facility is not the renovated foyer and positive balance sheet; it is the ability to find a staff member who is engaged in their work and loves their job and their residents. I have seen too many of the former and not enough of the latter.
The system has already failed too many of our elderly Australians; to accept the status quo would be to turn failure into abject tragedy, that the suffering they have needlessly endured would be in vain. We can and should do better.
Dr Stephen Dick is currently training in palliative medicine. He has previously worked as a rural and urban GP with a special interest in internal medicine and aged care.
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.