Aged care: a shocking tale of neglect, indeed

AN emaciated man in his 80s was bedridden on layers and layers of newspapers in a futile attempt by his apathetic son to cover up the stench of faeces and urine. The trauma of being confronted with this abhorrent case of elder abuse on a home visit as a young GP over 30 years ago still haunts me. But walking away and turning a blind eye was not an option then, and it’s not an option now.

Just over a week ago, the Royal Commission into Aged Care handed down its grim interim report, after receiving over 6600 submissions, and conducting many formal hearings, community forums, service provider visits, and roundtables since October 2018. The 780-page document calls for urgent action by the government on only three issues, after re-exposing the multitude of well known concerns, including criminal cases of elder abuse. The three recommendations are:

• to provide more Home Care Packages to reduce the waiting list for higher level care at home;
• to respond to the significant over-reliance on chemical restraint in aged care, including through the seventh Community Pharmacy Agreement; and,
• to stop the flow of younger people with disability going into aged care, and expediting the process of getting younger people who are already in aged care out.

The release of the Commission’s major recommendations has now been delayed until mid-November 2020 because it requires more time to uncover the layers and layers of complex problems.

However, very few of the past recommendations of the 18 reviews and inquiries into aged care over the past 20 years have been implemented by successive governments, and the aged care sector is again in a painful limbo while the Commission has been extended. Ongoing negative scrutiny will result in a perfect storm, exacerbating the exodus of dedicated aged care clinicians and carers and threatening the viability of providers already compromised by workforce shortages (here, here, and here).

Many systemic issues also have a negative impact on the ability of medical practitioners to provide high quality health care to senior Australians. After watching individual doctors being held to account by the Royal Commission over the past 12 months, many now fear being held directly or indirectly liable when common systems issues have been undermining the quality of aged care for decades – inadequate aged funding, high levels of family and occupational violence, lack of access to appropriate health care resulting in inappropriate admissions to acute hospitals, and lack of regulation and training of personal carers to name just a few.

In the foreword of the interim report, the Commission highlighted the following examples of substandard care in residential aged care which clinicians are responsible for managing:

• the Dietitians Association of Australia use current research to estimate that 22–50% of people in residential aged care are malnourished;
• an analysis of Aged Care Funding Instrument data reveals much higher than expected rates of incontinence, 75–81% of residents, with the majority in the most dependent category;
• recent Australian research reveals that pressure injuries occur in one-third of the most frail aged care residents at the end of their lives;
• research involving 150 residential aged care facilities found that 61% of residents were regularly taking psychotropic agents, with 41% prescribed antidepressants, 22% prescribed antipsychotics, and 22% prescribed benzodiazepines;
• an Australian Department of Health expert clinical advisory panel estimated that psychotropic medication is only clearly justified in about 10% of cases in which they are prescribed in residential aged care;
• there were 4013 notifications of alleged or suspected physical and/or sexual assaults in aged care in 2017–18.

At first glance, these statistics could be interpreted as a slur on the quality of care in residential aged care. However, it is not known what proportion of the alleged substandard care actually originated while senior Australians faced prolonged waits or received Home Care Packages, before being admitted to facilities in a frail state for intensive management. It is also difficult to quantify these statistics for senior Australians preferring to stay in their own homes, but it is more likely that these common issues, including family violence in all its forms, continue undetected and are worse than in residential aged care.

This point is important because the Morrison government is currently considering more Home Care Packages to reduce the enormous waiting lists for higher level care at home, but has not yet commented on the need to also urgently address inadequate funding of residential aged care, GPs and other primary care professionals during an epidemic of undertreated complex chronic disease in our rapidly ageing Australian population.

Of concern is that the voice of doctors is largely silent in the interim report, except for the alleged high levels of prescribing of psychotropic medication, including antidepressants, benzodiazepines and antipsychotic medication, in residential aged care by GPs. One of the three interim recommendations by the Commission is for the Morrison government to act immediately to reduce the “significant over-reliance on chemical restraint in aged care”.

As a first action after receiving the interim report, the Morrison government delivered a united agreement from Health Ministers for better management of medication in aged care, by recognising Quality Use of Medicine and Medicine Safety to be a National Health Priority. In the near future, GP prescribing will be audited and GPs will be required to seek an authority before prescribing antipsychotic medication. It also has been suggested that, in the future, psychotropic medication should only be prescribed by geriatricians and psychiatrists, with strict supervision by pharmacists in residential aged care.

There was a lack of acknowledgment in the interim report of how GPs provide essential clinical services to senior Australians in residential aged care and at home. Similarly, there was no mention of the significant work of the Royal Australian College of General Practitioners to upskill GPs by recently releasing an updated version of the Silver Book and drafting aged care standards for GPs visiting residential aged care.

If a prolonged Commission results in apathy, a punitive blame game between different medical specialties and stakeholders, or an exodus of clinicians, carers and providers, it will inadvertently result in further damage to the aged care sector. While many doctors are leaving the aged care sector “because it’s all just too hard”, walking away from the stench uncovered by the Royal Commission and turning a blind eye are not constructive or humane options.

It is time for the medical profession to unite and join forces with aged care providers to call for further urgent action by the government.

As the Royal Commission concluded in its interim report:

“It is clear that a fundamental overhaul of the design, objectives, regulation and funding of aged care in Australia is required.”

We cannot wait another 12 months for the Commission to finish before we start on the essential journey of aged care reform.

If you agree, please call, visit or write to your member of Parliament to make your voice heard.

Clinical Professor Leanne Rowe AM is a GP, non-executive Director of Japara Healthcare Pty Ltd and past Chairman of the Royal Australian College of General Practitioners. Her book Every Doctor: healthier doctors = healthier patients was published by Taylor and Francis recently.

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.