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After the Royal Commission, aged care reform faces a long road

After thousands of submissions, more than two years of work and 23 public hearings, can Australians expect that the Royal Commission into Aged Care Quality and Safety will lead to transformative change?

In his preface to the Commission’s final report, tabled in Parliament on Monday, Commissioner Tony Pagone QC notes that he and fellow Commissioner Lynelle Briggs AO could not agree on all of their recommendations for how the system can be improved.

He adds, in what might be viewed as an optimistic, admonitory or a pleading note:

Our disagreement about the best way for improvement to be achieved is not a justification for doing nothing.”

Pagone also references evidence presented to the Commission by Uncle Brian Campbell in October 2019, who asked:

I’ve sat with Royal Commissions into deaths in custody. I’ve sat with the Bringing Them Home hearing; right? And out of all of them hardly anything gets done, and is this one going to be the same?.”

Given the history of aged care (so many inquiries, over so many years) and of Royal Commissions, it is not surprising there is widespread concern that all the work – not only of the Royal Commission team but all who made submissions and engaged with the process – will not lead to real and lasting improvements in the care provided to older Australians.

(Here it’s worth reminding readers that, as the Commission noted, aged care is not a single system but encompasses a range of services provided in people’s homes, in the community and in residential aged care settings. The report says: “People commonly think of nursing homes, or residential care, when they think about aged care. However, while most of the aged care budget is spent on residential aged care, more than two-thirds of people using aged care services do so from home.”)

Fundamental concerns

Kathy Eagar, Professor of Health Services Research and Director of the Australian Health Services Research Institute at the University of Wollongong, and her colleague Anita Westera say the report is “full of inconsistencies, contradictions and conflicts” and has handed both government and aged care providers a ‘get out of jail’ card.

They argue that the Commissioners’ failure to agree on critical issues reflects a fundamental conflict:

One Commissioner sees government as the problem. The other Commissioner sees government as the solution. As the final report illustrates, it is impossible to reconcile such a fundamental difference.

They have thus handed the most recalcitrant issues back to government to solve.”

Writing at the Pearls and Irritations site, Eagar and Westera also say the report fails to question the underlying assumptions about aged care as a market:

Furthermore, for the many thousands of people who wrote submissions setting out serious incidences of abuse and neglect, it is likely they will feel particularly aggrieved that the ACRC appears to have made no adverse findings against any provider. They will inevitably conclude that they were not heard.”

Nor has the Government’s response inspired confidence.

Some journalists noted that the Government’s failure to provide them with access to the report in advance (by contrast with what happened with the release today of the Victorian Royal Commission report into mental health) was emblematic of the Government’s reluctance to engage with the hard questions arising from the report.

To date, the Government’s response to the Royal Commission’s work, including its interim reports and research publications, has been “slow and superficial,’ says Alison Verhoeven, CEO of the Australian Healthcare and Hospitals Association (AHHA).

In a statement, she said the Government must not allow the Commissioners’ divergent views relating to governance and funding to get in the road of doing what’s right for older Australians.

“We cannot put off these urgent requirements with excuses about limited budgets,” she said. “If the Australian Government can find money to invest in over-budget submarine and Joint Strike Fighter projects, it is surely only reasonable to expect appropriate resourcing to care for older Australians.”

Act now

Verhoeven said at the very minimum, action is needed now to:

  • Increase the number of home care packages, and ensure that people are receiving packages at the level they have been assessed as requiring in a timely manner
  • Reduce the number of younger people in residential aged care, and ensure their access to appropriate accommodation and care services
  • Ensure people living in residential aged care are provided with appropriate personal care services, healthy food, and support to live comfortable and meaningful lives
  • Improve wages and employment conditions for aged care staff
  • Ensure aged care staff are appropriately qualified and receive professional development, including in palliative care and dementia support
  • Ensure funding is available to support the employment of registered nursing staff in residential aged care services 24 hours a day
  • Improve support for general practice services in residential aged care, including MBS funding for regular health checks
  • Improve the regulatory and complaints processes to ensure both accountability of aged care providers and opportunity for residents and carers to put forward complaints and have these responded to effectively
  • Improve transparency on how taxpayer dollars are used by aged care providers.

The Victorian Healthcare Association Chief Executive Tom Symondson said it was disappointing the Commissioners could not agree on a unanimous vision for reform and “it is critical that this disagreement does not lead to confusion and delay that limits the impact of this Royal Commission”.

On a similar note, the Grattan Institute’s Professor Stephen Duckett and Anika Stobart said the Commissioners’s divergence around some of the recommendations reduced the power of the report and made “the already complex path to reform even more confusing”.

“More disappointingly, it gives the government room to pick and choose recommendations as the cabinet likes,” they wrote in The Conversation.

These authors say Commissioner Briggs has the more persuasive proposal for funding the new system. She wants the government to introduce legislation by July 1 2022 that establishes an aged-care improvement levy of one percent of taxable personal income.

Commissioner Pagone wants the Productivity Commission to investigate the establishment of an hypothecated aged-care levy (meaning the money raised by the levy can only be spent on aged care).

Duckett and Stobart says that either approach will be politically difficult, “but Australians should demand their government lock-in a secure funding supply”.

As we wait to see what the Federal Budget delivers for aged care, the Royal Commissioners want the Australian Government to report to Parliament on its response by the end of May:

The report should indicate whether each recommendation directed to the Australian Government is accepted, accepted in principle, rejected or subject to further consideration. The report should also include some detail about how the recommendations that are accepted will be implemented and should explain the reasons for any rejections.”

Key recommendations

Duckett and Stobart said the recommendations could be broadly summarised in four categories: that we need rights-based aged care; the system needs stronger governance; we need to improve workforce conditions and capability; and that a better system will cost more.

Below, Croakey has summarised some key recommendations.

A new Aged Care Act should be in place by no later than 1 July 2023, aimed at providing a universal right to high quality, safe and timely support and care, to protect and advance the rights of older people receiving aged care to be free from mistreatment, neglect and harm from poor quality or unsafe care, and to continue to enjoy rights of social participation accessible to members of society generally.

An Australian Aged Care Commission (recommended by Commissioner Pagone) should be established by 1 July 2023, with wide-ranging functions.

Australian Aged Care Pricing Authority (recommended by Commissioner Pagone) should be established for determining prices (inclusive of subsidies and user contributions) for specified aged care services so as to meet the reasonable and efficient costs of delivering those services. Its functions should include the function of identifying and recommending to the Australian Aged Care Commission the aged care services for which price cap determinations or other forms of economic regulation may be appropriate.

Aged Care Advisory Council (recommended by Commissioner Pagone).

Cabinet Minister and Department of Health and Aged Care (recommended by Commissioner Briggs): The Australian Government should ensure in all future Ministerial arrangements that there is a senior Cabinet Minister, preferably the Minister for Health and Aged Care, responsible for aged care. The Department of Health should immediately be renamed the Department of Health and Aged Care.

The Council of Elders (recommended by Commissioner Briggs): The Australian Government should, by 1 July 2021, establish  a high-level older people’s advisory body—The Council of Elders— with a wide remit to consult older people and advise the Minister and Department on any aspect of aged care from the perspective of the quality and safety of care and the rights and dignity of older people.

The Aged Care Quality and Safety Commission should be abolished by 1 July 2022 and replaced by an independent Aged Care Safety and Quality Authority, overseen by a board made up of up to five members, with a Chief Executive Officer responsible to the Authority (recommended by Commissioner Briggs).

The Independent Hospital Pricing Authority should be renamed by 1 July 2021 as the Independent Hospital and Aged Care Pricing Authority  (recommended by Commissioner Briggs).

A comprehensive, clear and accessible post-diagnosis support pathway for people living with dementia, their carers and families should be established by 1 January 2023.

By 1 July 2023, the Australian Government should review and publicly report on whether the number of specialist dementia care units established or planned to be established is sufficient to address need within the areas and populations they are designed to cover.

Regulation of restraints: The Quality of Care Principles 2014 (Cth) should be amended by 1 January 2022 to ensure the use of restrictive practices in aged care must be based on an independent expert assessment and subject to ongoing reporting and monitoring. The amendments should reflect the overall principle that people receiving aged care should be equally protected from restrictive practices as other members of the community.

Aged care standard-setting by the renamed Australian Commission on Safety and Quality in Health and Aged Care. By the end of 2022, the Commission should complete a wide-ranging review of standards, including those regarding best practice oral care, medication management, pressure injury prevention, wound management, continence care, falls prevention and mobility, and infection control, residents’ nutritional needs, provider governance, palliative care and dementia care.

A single comprehensive assessment process. The Australian Government should replace the Aged Care Assessment Program and the Regional Assessment Services with one assessment process by 1 July 2023.

Care finders should be funded by the Australian Government from 1 July 2023, as a workforce of personal advisers to older people, their families and carers (recommended by Commissioner Briggs).

Training in cultural safety and trauma-informed service delivery should be provided for all workers from mid 2022, as part of a recommendation called “Designing for diversity, difference, complexity and individuality”.

Aboriginal and Torres Strait Islander aged care pathway within the new aged care system so that Aboriginal and Torres Strait Islander people receive culturally respectful and safe, high quality, trauma-informed, needs-based and flexible aged care services regardless of where they live.

Priority should be given to existing and new Aboriginal and Torres Strait Islander organisations, including health, disability and social service providers, to cooperate and become providers of integrated aged care services.

An Aboriginal and Torres Strait Islander Aged Care Commissioner should be appointed by 1 July 2023.

Aboriginal and Torres Strait Islander organisations should be assisted by the Australian Government to expand into aged care service delivery, whether on their own or in partnership with other organisations, including with Aboriginal Community Controlled Organisations and existing Aboriginal and Torres Strait Islander providers.

A comprehensive national Aboriginal and Torres Strait Islander Aged Care Workforce Plan should be developed by 1 December 2022, in consultation with the National Advisory Group for Aboriginal and Torres Strait Islander Aged Care.

Older people in regional, rural and remote locations should are able to access aged care in their community equitably with other Australians, with a range of recommendations around extending the Multi-Purpose Services Program.

A new primary care model would be developed so that general practices could apply to the Australian Government to become accredited aged care general practices (the Commissioners had different views on how this would be introduced although both wanted it up and running by the start of 2024). By the end of 2021, the Commissioners wanted the Royal Australian College of General Practitioners to amend its Standards for general practices to allow for accreditation of general practices which practise exclusively in providing primary health care to people receiving aged care in residential aged care facilities and in their own homes. [The RACGP does not support this model, arguing that it creates more barriers for GPs wanting to care for their patients in aged care facilities].

By the beginning of next year, Australian, state and territory governments, through the National Health Reform Agreement, should introduce Local Hospital Network-led multidisciplinary outreach services for people receiving residential care or personal care at home based on clinical need. Mental health outreach services also should be provided like this, while other recommendations aim to improve access to allied health services and specialist telehealth services.

By the start of 2023, the Australian Government should establish a new Senior Dental Benefits Scheme to fund dental services to people who live in residential aged care, or live in the community and receive the age pension or qualify for the Commonwealth Seniors Health Card.

From the start of next year, the Australian Government should immediately improve access to quality medication management reviews for people receiving aged care by allowing and funding pharmacists to conduct reviews on entry to residential care and annually thereafter, or more often if needed.

Restricted prescription of antipsychotics in residential aged care. By 1 November 2021, the Australian Government should amend the Pharmaceutical Benefits Scheme Schedule so that only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care, with GPs able to issue repeats for up to a year.

To improving data on the interaction between the health and aged care systems, the Government should implement an aged care identifier by no later than 1 July 2022 in the Medicare Benefits Schedule and Pharmaceutical Benefits Scheme Schedule datasets to allow regular public reporting on the number and type of medical and pharmaceutical services provided to people receiving aged care.

Universal adoption by the aged care sector of digital technology and My Health Record, by mid 2022.

The Australian Government should immediately put in place the means to achieve, and to monitor and report on progress towards, the PM’s commitments announced in 2019 that from the beginning of next year: no person under the age of 65 years enters residential aged care; and no person under the age of 45 years lives in residential aged care. Also the commitment that from the beginning of 2025, no person under 65 years lives in residential aged care.

A national registration scheme for the personal care workforce should be established by mid 2022.

By mid 2022, all aged care workers who are involved in direct contact with people seeking or receiving services in the aged care system undertake regular training about dementia care and palliative care.

From 1 July 2022, the minimum staff time standard should require approved providers to engage registered nurses, enrolled nurses, and personal careworkers for at least 200 minutes per resident per day for the average resident, with at least 40 minutes of that staff time provided by a registered nurse. At least one registered nurse should be required on site per residential aged care facility for the morning and afternoon shifts (16 hours per day).

From 1 July 2024, the minimum staff time standard should increase to require approved providers to engage registered nurses, enrolled nurses, and personal care workers for the average resident for at least 215 minutes per resident per day for the average resident, with at least 44 minutes of that staff time provided by a registered nurse. At least one registered nurse should be required on site per residential aged care facility at all times.

Many recommendations aim to improve the quality and accountability of the governance of aged care providers, as well as improvements in complaints processes, serious incident reporting and protection for whistleblowers.

Other recommendations aim to boost research and innovation in aged care.

Findings and context

The Commissioners reported that the aged care system is difficult to access and navigate.

“People trying to get aged care have reported the experience as time-consuming, overwhelming, frightening and intimidating. The availability of helpful and comprehensive information is critical to ensuring older people get timely access to the care they need and to empowering them to make choices about their care,” they said.

They also described an “unacceptable” level of substandard care, with a reluctance in the system to measure quality of care: “Those who run the aged care system do not seem to know about the nature and extent of substandard care, and have made limited attempts to find out.”

Commissioner Briggs further notes that the extent of substandard care differs across different provider types, including the organisation type – for-profit, not-for-profit, government – as well as the size and business model of the provider.

According to a range of measures of quality and residents’ outcomes, government-run residential aged care providers perform better on average than both not-for-profit and, in particular, for-profit aged care providers.

Research indicates that quality in residential aged care services is highly correlated with size, with small residential care services (fewer than 30 beds) performing better on average than larger services.

The Commissioners state:

The extent of substandard care in Australia’s aged care system reflects both poor quality on the part of some aged care providers and fundamental systemic flaws with the way the Australian aged care system is designed and governed. People receiving aged care deserve better. The Australian community is entitled to expect better.”

From Twitter

Further reading

Nursing Review: A watershed moment

ABC: Investigative journalist Anne Connolly with some useful context

ABC: More from Anne Connolly on why she is hopeful about aged care

The Conversation: Michelle Grattan’s analysis

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