Doctor and activist


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Category: Medicare

What is Needed in Health

12 May 2022

Dr Stephen Duckett was an architect of Medicare and is one of our leading health policy experts. His opinion of what is needed for the health system has a lot of implied criticism of what has been happening, with excessive resources on late-stage treatments rather than prevention and early diagnosis, which comes in Primary Care.He speaks of the dis-cordination, cost shifting and political nature of decision-making.

He does not even mention the need to fix Medicare- saving it is not enough!

What I would do if I were the Minister for Health and Ageing in the next government

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Loneliness and its solutions

25 February 2022


I sometimes watch Foreign Correspondent on ABC TV and by chance on 15/2/21 I came across this excellent programme on loneliness in Japan.


The ABC correspondent there looks at loneliness in the Japanese population from older folk dying alone, to younger people simply withdrawing from society.


Some of the older ones had no family or jobs. Some of the younger ones were so pressured to succeed and felt that they had failed, so simply withdrew from society. It seems that the pressure on kids all to be CEOs is an absurd and unachievable objective.


I am not sure that the situation in Australia is as bad, but I thought about some of my patients and could think of half a dozen immediately. With some of them , I am one of the only two or three people in the world they have any contact with, their relationships are tenuous.


None of them started with mental health problems. Here are some examples:


A 60 year old man worked for a security company looking after an insurance company. He was doing surveillance for them, but it took over his life as he was contacted 24 hours a day for various crises. Case management employees having conscience over what they were doing had to be rescued from self-harm in the toilets. Enraged claimants with refused claims threatened to blow up the company offices with cans of petrol. He saw staff high-fiveing as some claimant got a derisory settlement when they deserved and needed a lot more. It went on like this for years. When he said that he could not do this anymore he was treated as badly as any of the people he had dealt with. He told me this story, and I had hoped that with his considerable management skills and experience, he could be put into a less stressful position. But he deteriorated. Everything reminds him of the corruption of the world. He is estranged from his wife and they communicate with post-it notes on the frig. He goes for a walk at 11 at night so he will not have to speak to people in the street. One son has stuck by him and visits daily, and will build him a self-contained unit in his new home.


Another patient is a 62 year old ethnic taxi driver who was so badly bashed 11 years ago by a gang stealing his takings that he lost an eye, has never worked again and never recovered mentally or physically. He was divorced; lives alone and sometimes will not even answer the phone.


One is a 42 year old foreign student who came to study theology, wanting to become a pastor. Her English is not great. She is a trifle unworldly, and thought that the world is basically kind and people look after each other. She had a casual job in a motel and her boss asked her to move a bed down the stairs between floors. She said it was too heavy and she could not, but he threatened to sack her. She did it and got an injury to two discs in her back. She was frightened to have surgery, so was in agony for a couple of years and eventually agreed. She had minimal surgery, which was not successful. The insurer decided that she was not complying with what they wanted so refused to pay her. She was effectively broke and homeless, so an old lady from her church offered her a bed and food. But she lives a long way away and up a drive that is hard for my patient to walk up. She was effectively trapped. As a foreign person she did not even have Medicare for the minimal psychological help it offers (6 visits a year). Her mental health deteriorated and she shunned all outside contact, and would not even answer the phone. She has gone home to her family- I can only hope she improves there.


One is a 39 year old from a religious and teetotal family with a high sense of ethics. He was a top salesman of a computer company and became aware that they were ripping off some customers. He drew this to management’s attention, but they declined to do anything and he was labelled a whistleblower. Management supported him by putting out an email asking that he be supported for his mental health issues. He felt that this ostracisation was the end of his career, because he had asked them to behave ethically. He was certain that no one in his tight top group will now employ him, so he withdrew and started to drink to lessen the pain. His family then rejected him because of the drinking and his sales friends are estranged also. The psychologist gives him Cognitive Behavioural Therapy exercises and I try to get him to drink less and somewhat ironically counsel him that you cannot withdraw from the world merely because the baddies generally win. He lives alone, answers the phone and is just able to do his own shopping, but is not improving much.


These are just some examples that I know. Coasting home as GP at least keeps you in contact with life. The point is that many people have broken lives, but just keep living. None of these examples have done anything wrong themselves. Is a sense of ethics a mental illness?


As everyone has to ‘look after themselves’ in a consumer-oriented society, more people will fall through the cracks, especially as the gap between rich and poor is enlarged by pork barrelling which puts resources into areas that need them less, tax breaks for the rich, subsidies for private schools and private health insurance, derisory welfare payments, and insurers allowed simply to refuse to pay without penalty.


People need basic support with universal housing and universal health case. They need jobs or at least occupations and an adequate income to survive. And we need outreach and support services that can be called upon.
When people say, ‘There are not enough jobs’, they are taking nonsense. Anyone can think of many worthwhile things that need doing. And there are plenty of people who would be happy to do them. The problem is that in a world where nothing can be done that does not make a profit, a lot of things that need doing are not done. That is where the policy change are needed. We cannot simply look at the money and see to what level existing activities can be maintained. We need to look at what needs to be done, and then work out how to achieve it. We need to decide that everyone has a right to live and those who have a good life will live in a better society if everyone can share at least a basic quality of life. There has to be recognition that the ability to be profitable need not be the overwhelming criterion for what is done. Tax may go up, but if there is real re-think of priorities, it is not likely to be all that much.


The link to the ABC program that initiated this tirade is below.
https://iview.abc.net.au/show/foreign-correspondent/series/2022/video/NC2210H002S00

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COVID Day 4- a non-PCR Day

5 January 2022

I did nothing today- it just took longer than usual.

I felt much the same, a sore throat, not much energy, a bit of a headache and bouts of a dry cough. I did not feel like exercise and I thought that I had better try to get a PCR test and some Rapid Antigen tests in case we needed to prove we were not infectious, or had other people who were concerned contacts.

I researched online where the PCR (Polymerase Chain Reaction) tests were being done. The site I used 2 weeks ago, a 4Cyte drive through test that had taken an hour to do and 3 days and 16 hours to get results from was closed Wed-Friday. It was not clear why this was but the Laverty Pathology group at 60 Waterloo Rd near Macquarie Centre was open till 4pm. I took a novel in case of a long wait and drove there.

As I approached from the google direction cars in the left lane were not moving from the major intersection as far as one could see to the next hill. Many of them had their tail lights on, so I reflected that they were sitting in a line with the engines on. Bad for the environment, but it at least told me that his was the queue. I turned off the engine and started to read. After a while I was wondering why no progress at all was being made, and I thought I might ask if I was under some misapprehension. As I looked up, a pleasant looking woman in her mid-30s got out of the small car ahead, and went to her boot.

I called to her out the window, ‘Is this the PCR test queue?

‘Reckon so’, she said, ‘I’ve brought some snacks to get through it’. She took some biscuits, grapes and a drink and got back in.

We advanced glacially slowly, and I noticed that there was a side road a little way down the queue. Space had been left so cars could go in and out of this side road, but cars had also started to queue there, and of course the two queues merged at the intersection. I had not thought of this until I was nearly at the corner, and I suppose the woman in the car hadn’t either. Some on the side road were shouting abuse or tooting as if we were somehow pushing in to their queue. There were no signs, no guides and nothing online, so it seemed that the only fair thing to do was to take alternate cars. My young friend had recognised this before I had and moved her car across the middle of the side road, so that cars exiting or entering could go in front or behind her, but she could be sure that the side road queued cards did not just push in. There was a cacophony of abuse from the side street.

The queue moved forward a few cars, so I followed her closely, letting one car in as seemed fair. A large 4WD with a man screaming obscenities at me tried to push in, but I kept him out. I wondered if he would get out and make trouble but he did not. The passenger in the car I had let ahead of me had got out and was remonstrating with the woman who had been in front of me. It was tense. I was very glad we were not in America with some people having guns.

We continued our glacial advance, then a car coming in the other direction stopped. The driver stuck his head our and was shouting something to those in the queue ahead of me. I could not hear him, but he did not seem abusive, so as he passed I called to him to ask what he had said. He said, ‘They have closed early; I was second in the queue and they told me to go away’. It seemed likely that he was right, but most people had waited so long that they were not willing to drive off, so we moved quite slowly till everyone had driven past the ‘Closed’ sign that had appeared in the driveway. It was 2pm. The testing site was advertised to be open till 4.

No test and a couple of hours wasted. I have COVID. It is not recorded in the system. It seems that I will recover. Will I waste another few hours tomorrow? And if I do will I have PCR results anyway? I am scheduled to see my patients again 9 days after the onset of symptoms- presumably I will be non-infectious. Luckily I got some RAT kits.

It is not hard to see where anger and frustration comes in all of this.

‘Personal responsibility’ has a very Darwinian edge.

Thank God I am not very sick.

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Victorian Government Bites the Bullet and Mandates Vaccination

22 September 2021

At last!  A government that does the sensible thing.  The Victorian government will only open up if people are vaccinated.  Thanks to NSW the Delta variant genie is out of the bottle and spreading nationwide.  Business wants to unlock, some with no care for anyone but themselves.

Victoria wants to unlock but minimise spread among those now having more interpersonal contacts.  The R (Reproduction) number is the number of cases each case infects.  If everyone is vaccinated, less people will get it and those who have it will get it to less people.

Reasonable medical opinion is that the risks of vaccine are massively less than the risks of getting COVID, so the case against vaccination is incredibly weak on medical grounds.  The ‘right not to have your body violated’ etc sounds very dramatic, and makes vaccination equivalent to rape in a semantic sense.   But in a practical sense the two concepts are as far apart as could be.  One is sensible medicine and the other is a crime.

Anyone who thinks that this does not matter should look at the graph of NSW cases that has peaked and is just starting to fall.  Anything that can flatten the curve or make it fall is good. Anything that makes it rise is creating deaths and misery.

I am a member of the Council for Civil Liberties and have spent years working against excess government power. But sometimes it is necessary to act for the common good.  I have no time for smokers’ rights or the right to spread disease.  The Morrison government is as usual missing in action when real leadership is needed.  ‘Let every workplace decide’, is a nightmare for retail business owners, offices and just about every other employer. Gladys is similarly missing.  Dan Andrews has stepped up, despite a motley crew in the streets spreading disease and demanding the right to continue to do so.

What of the Health System?  We are going the way of the Americans by stealth, and the fact that the public system is what has helped us survive is being glossed over, hidden  by subsidies to private hospitals. The Federal government has been quietly trying to kill public medicine for years. The Medicare rebate has fallen from 85% of the AMA rate to 45%, so for the same bulk-billing work doctors incomes have almost halved over 35 years, while subsidies to the inefficient Private Health Insurers continue.  Being a GP is now a little-sought speciality.  (I have a FB page- Fix Medicare that I spend too little time on).

The States have maintained the public hospitals at a minimal level, as all the lucrative work has been siphoned off by the private system basically doing the easy stuff.  There is No slack in the system, not that counting the number of ICU beds should factor.  All our efforts should be to keep people out of Hospital and ICU by prevention of infection. 

Have a look at this article on the anti-discrimination aspects of mandatory vaccination, and also look at the NSW cases, just turning down, but likely to rise if anything, like opening up from lockdown, tips the balance.

www.smh.com.au/national/victoria/here-s-why-no-jab-no-entry-is-not-discrimination-20210920-p58t2v.html?fbclid=IwAR2jrbfGJsq6fD-J-unnAn12j9UyWvdk-do5BpE23bI0z0gQ8kknq5nc39c

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What Has Gone Wrong in Australia?

8 September 2021

John Quiggin gives a good, insightful summary in The Monthly.

www.themonthly.com.au/issue/2021/september/1630418400/john-quiggin/dismembering-government?utm_medium=email&utm_campaign=The Monthly Today – Wednesday 8 September 2021&utm_content=The Monthly Today – Wednesday 8 September 2021+CID_77319af0620e0ea97965a0e5af6e7e60&utm_source=EDM&utm_term=The Monthly#mtr

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NDIS Individual Assessments; A Symptom of a Wider Problem

10 July 2021

The current issue in the NDIS (National Disability Insurance Scheme) is the government’s efforts to introduce ‘independent assessments’ of people on the scheme and those who want to get on the scheme.  The idea has been abandoned for the present, but that is not the end of the story. It is the beginning.

Some context is needed here.  I was on a State Parliamentary inquiry into disability funding during which we heard evidence of inefficiencies within the disability sector where often there were shortages of appropriate services, and in some areas there were none at all.  The real crunch time was when parents with children with disabilities realised that they were going to die eventually and wanted to make a plan for the rest of their child’s life.  People would apply at various facilities, and be turned away as there were no places.  They then assumed that they were on a waiting list, but usually no lists were kept. When a vacancy occurred, whoever applied at that time got it.  It was mainly luck.  Naturally the people trying to help their loved one wanted a guaranteed package that would continue after their death.  More articulate parents and carers, who had struggled for years just wanted the money to buy the services that they felt that they needed. Many carers simply wanted more services, and hoped that a national system that guaranteed services for disability.  

Given the political context of privatisation and reducing government involvement in everything, the scene was set to have disability services delivered by the private sector as a massive market for services.   The private sector naturally wanted to get access to services that had been provided by government as a source of business and profit.

Government also had a real estate agenda.  Some large institutions were on valuable land. The large facilities at Peat Island in the Hawkesbury and Stockton Disability Centre was on beachfront land just north of Newcastle.  There was a residence for the grossly disabled opposite Wollongong Hospital that had taken years of fundraising for the parents to achieve.   These could be sold off as the mental health facilities had been a few decades earlier, with the catchy slogan of putting the residents ‘back in the community’. The idea that the residents were better off isolated in a suburban homes with few facilities rather than in a community of people with the same problem and a well-structured programme of activities seemed a dubious proposition to me.  Resident groups such as the relatives of long-term psychiatric facilities at Bloomfield in Orange were very scared of the suggested changes.  There had been problems with the old system and some inappropriate facilities, but an overall lack of facilities was the major problem.  It was not even throwing the baby out with the bathwater; it seemed more like smoke and mirrors. 

The key question in dealing with any problem is how big a task is it?  When the Committee asked how many people with disabilities there were, there was no answer.  No register was kept.  The two ways of calculating it were:

  1. To add up all the people on all the types of possible benefits and get to a total. 
  2. To look at the AIHW (Aust. Institute of Health and Welfare) figures of what percentage of the population was disabled, then multiply this by the total population. 

The latter method gave figures about ten times greater.  So clearly if help or services were made more available, the numbers involved were going to blow out hugely from what was currently funded.

John Howard passed the Aged Care Act in 1998, which was the blueprint for the privatisation of the sector. Old people are very vulnerable. They have often sold the family home, so they are temporarily cashed up, looking for accommodation and long term care with mental and physical facilities failing, or they would not be there.  Carers faced with responsibilities that they were not used to and uncertain of what care was needed were easy pickings also.  The whole sector is more like a dysfunctional real estate market; a market failure due to insufficient ‘consumer information’, but also distorted incentives and priorities.

The NDIS was similar.  Private operators with slick marketing made promises which would not be tested for some time, but people were signed up now.  The not-for profit sector had never paid staff well, but most had a ‘care ethos’.  Some of the private providers did not, and regulatory supervision was minimal. The government was pro-business and trying to give away responsibility. 

But an absolute shortage of services was still a big factor.  A neighbour who was a 95 year old retired academic widower wanted 2 hours a week of home help.  For some reason he could not get a community nurse.   The best deal he could get was 2 sessions of 2 hours at $65 an hour.  The lady delivering the service was paid $21/hr.  So much for private services; the ‘overheads’ are huge.  I had suggested to Kevin Rudd’s 2020 Vision in 2000 that the Government needed to licence service providers as individuals if they wanted a market model, and our neighbour could have selected a person on a one to one basis.  (I never even got an acknowledgement).

Now the government wants ‘independent assessors’ to evaluate cases, presumably to lessen costs.  A number of points can be made about this.  It assumes that the assessors will learn more about the patient in an interview than the people who work with them already know.  The new management philosophy since the 1980s always assumes that a manager at the top will know more than the person actually doing the job.  Naturally if the object is to save money and have the person at the bottom paid minimally, requiring no skills and interchangeable in staffing, this may be true.  But if the people at the bottom were respected, trained and empowered, the need for the middle level experts might be much less.

‘Independent Medical expert’ assessors are used in the Workers Compensation and CTP systems.  They work for agencies hired by insurance companies.  Often they find the patients either have nothing wrong with them, or it is degenerative and not related to their injury.  These experts are even flown from interstate and save insurers money by denying treatments. Presumably if they find in favour of the patients, their agency gives them less work.  The agency takes its cut and has to please the insurer.  So the systems are more complicated and an ever higher percentage of the money is spent in trying not to give services.  The NZ National Accident Compensation scheme, though it was government owned, went to a private insurance model and the same thing happened.  Doctors who had a track record of denying liability were flown around the country to do their medicals.

The assumption may still be that well intentioned assessors still can do better.  My widowed mother lived alone in the family home and had a stroke.  A neighbour noticed her confused, walking on the balcony.  She recovered, but seemed to have lost some judgement.  She was assessed by an ACAT (Aged Care Assessment Team) who said that she could live alone in supported accommodation. So we got her into a unit in the grounds of an old house, where she could book a dinner at a days’ notice in the communal dining room, have a nurse onsite during the day, and had a right to a nursing home bed if she ever needed one.  Seemed perfect.  She said that she could look after herself. Can you microwave a dinner?  Yes. OK. Do it.  It got done.  No problem. Dinners in the frig. Sweets in the jar on the mantelpiece; see you in 2 days.  Arrive in 2 days.  Dinners still in the frig. Lolly jar empty. Very hungry- can we go to lunch?  She could do anything when asked, but could not initiate a process. She could not think to get a dinner from the frig, or book lunch tomorrow in the communal dining room, nor ask for help.  The one-off team could not pick this.  Neither did the family. But it emerged when the situation at home was known. This is just a story, but a carer who is savvy and properly trained will know more than a university-qualified assessor who has only a short knowledge of the patient.  And naturally the person on the job actually delivers the service and is not an extra cost. They can also judge relative needs of people on a run or in an area if resources are limited.

So the scheme to bring in assessors is the tip of an iceberg. 

Private insurance models have huge problems at many levels.  The overheads of Medicare are a bit under 5%. The overheads of Private Health Insurers are about 12%, and they cannot refuse to pay doctors.  The overheads of US Health insurers are about 12-36%, as the best way to improve profits is to cut costs (payments to patients) rather than increase services and then try to prove you have and sell on that basis.  At the bottom of the efficiency barrel is our own NSW CTP system with overheads of almost 50%. The question has to be what is the focus of the system?  Delivering services, or saving money?  The US health insurers, like our CTP scheme are very good at making money.  What they make their money from just happens to be people rather than widgets.  The main cost savings of privatisation seems to be destroying award conditions and lowering ‘staff costs’.  The immense administrative savings from universal systems, where determining entitlement and paying for profits are eliminated cannot be matched by any private system, despite what the ideologues might pretend.

The NDIS is currently a fund supposedly to help people with disabilities.  These people apply to get ‘packages’ of money and services.  Businesses persuade people to spend their packages with them. It is a market.  But there are more people with disabilities than was expected, for the reasons discussed above.  So a new level of assessors, were to be rolled in, but a huge outcry has prevented this temporarily.  But the problems that led to the need for the assessors remain implicit in the design of the NDIS, which is fatally flawed.  The government, particularly this one, is not going to take this very large bag of lollies from the private sector.  The totally inefficient Private Health Insurers (PHI) give money to political parties and advance by stealth, letting Medicare become irrelevant for health care. Disability is now also privatised, and a new private lobby is in there.  It has not yet generated a Royal Commission into its rip-offs, but it will, not that the Aged Care Royal Commission has stopped the privatisation of aged care.  The political forces are too great.  It is ironic that as Medicare is starved and pays less and less of the doctors’ fees its levy was increased, using a wave of sympathy for people with disabilities to make a bigger pool of money for increasingly private disability providers.

How to fix the problem?

I do not pretend to have all wisdom on this, but in dealing with difficult political problems I think it is wise to set a direction, take some basic steps and consult widely, looking for advice particularly from those who do not get an immediate financial benefit.

Here is a start:

Recognise that disability is not a sickness.  Some disabilities are inherited; others are acquired due to accident, illness or aging. The sector is quite diverse, often divided up by the type of disability or how it was acquired.   Sickness has an ‘episode’ model, based on traditional infectious diseases or surgical treatment models. Disability tends to be long-term and may improve or be worked around, or may degenerate gradually. As such it needs long-term solutions like welfare, but using the term ‘welfare’ now implies charity. Disability funding is funding to enable those less fortunate to have as normal a life as possible. From our common wealth, we give more to those who need more so that our society has equal opportunity for all. We are being taught that tax must be minimised and if we are getting less than we pay we are being ripped off.  A better model is to consider the statement by Rhonda Galbally, ex-CEO of VicHealth, ‘There are two populations, the disabled and the not-yet disabled; if you are lucky enough to be in the second group, you should be happy to help pay for the first’.

The idea of a universal service obligation is the cornerstone.  We should start with the assumption that people with disabilities should live in our  society with as  normal a life as possible and we should adapt to support them in as cost-effective way as possible. 

My suggestion is that the Community Nursing service is the basic structural framework.  We assume that people with disabilities will be living in society, and need varied and integrated support.  If they are born with a disability or acquire one, they will come in contact with the acute hospital system, which will hopefully document their situation and alert the community support system.  People on the ground will then liaise with family to see what support there is for independent living, and organise resources, calling in specialists of required. The cost of home support may be part of a package or allowance.  Individuals may register to offer services for everything from shopping, cleaning and lawn mowing to medical or paraplegic support services.  The government will register and insure both practitioners and those who use their services and may put training requirements on those who wish to register for some skills.  A market with consumer feedback as exists for restaurants or other practitioners will allow people to hire help directly without big corporations adding massive overheads.

Whether the monies are paid separately of via Centrelink is an administrative question, but Centrelink has to have a major makeover so that it is not the niggardly decider of the ‘worthy poor’ with its chief function being to avoid paying anyone, or paying as little as possible.  If society cannot find everyone employment, we must share what we have to those who are disadvantaged by disability or circumstance. This will collide head on with the problem of increased numbers of those with disabilities, but the extra load must be seen as part of having a decent society. 

The way we are going seems to be privatising, allowing huge profits, then running out of money and shutting the gate on those who do not yet have packages.   The independent assessors were merely the instruments of Managers who were not able to make their own assessments and did not trust the people who actually deliver the services.  The assessor problem was the tip of the iceberg of a system that has all its underlying assumptions wrong, but sadly has a lot of  political power that having been created, may not be able to be undone.  The first step is to understand what is happening.  Hence this lengthy post.

www.abc.net.au/news/2021-07-09/ndis-disability-independent-assessments-model-dead-after-meeting/100277324

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CTP Insurers Pay 6.3% of Premiums to Injured People. They keep the rest.

28 May 2021

This is a huge corporate scam. Why do people think that only little people are rip-off scammers? Also the idea that most people claims are ‘accepted’ is a nonsense. Insurers accept the claim, which means that they pay for a few GP visits and some physio. But they refuse to pay for scans that might find diagnoses. Then they refuse to pay for referrals to specialists who might need to operate. Then they refuse to pay for recommended operations. Then they use tame doctors (IMEs = Independent Medical Examiners) who either say that the condition does not need the treatment or that the problem was there before the accident so the insurer is not liable.

So the government introduced the PIC (Personal Injury Commission) to arbitrate all the claims that the insurers had refused. Now the waiting time for the PIC is over a year, which suits the insurers fine as the doctors and patients will use Medicare or private heath insurance to get the treatments and the insurers will either pay less or not have to pay at all.

If you thought the banks were bad, you have not dealt with insurers. NRMA refuses a considerably higher percentage of treatments than anyone else in my statistics, and SIRA declines to keep statistics on the ‘industry’ as a whole, and no insurer has ever been prosecuted for refusing a treatment.

This is why we need Medicare- a single, just, efficient, universal health insurance scheme.

www.youtube.com/watch?v=Sp8R856f7cM

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Aged care: What is the prognosis? 15/11/20

I attended a DRS (Doctors Reform Society) zoom webinar on the future of health care with Professor Stephen Duckett and aged care with Professor Joseph Ibrahim of Monash Uni, a geriatrician whose experience is in evidence-based aged care.

It was not encouraging.

Preamble:

My own experience of nursing homes was initially as an after-hours doctor when I used to judge nursing homes by what I turned the Urine Smell Index; the worst ones smelled of urine when you opened the door at night.  As a GP years ago I found it increasingly difficult to find someone trained to talk to about the patients’ treatments.  

In New South Wales Parliament as an MP I was asked to pass legislation that lessened the number of trained nurses required on staff.  ‘Flexibility’ was the key and many homes and facilities ‘had people who were not really sick’ we were told.  I was not convinced but the legislation went through anyway.

When my widowed mother was no longer able to cope at home and the family went looking for supported accommodation it soon became clear that the driving force in Aged Care is real estate profits.  The family home is sold and the object is to get the family to buy an overpriced retirement Villa with varying levels of support in the villa and then hopefully automatic entry into an attached nursing home, usually with quite a poor urine smell index. When the old person dies the villa profit largely reverts to the corporation.

A dear old widower professor who lived up the road needed support in his 90s. The home support contract offered needed at least 4 hours per week at $65 per hour.  The person delivering the care was paid $20 an hour.  I am unsure how District Nurses are allocated.  

In 2000 Prime Minister Rudd asked for ideas for his ‘2020 Vision’.  I wrote and suggested that he register the skills and training of Home Care workers so that they could be hired and evaluated like Uber of any other online service and the ‘quality control and insurance’ would not be why the contracting agency became so ‘vital and expensive’ (that it would end up costing more than the person who actually did the work).  I never even had an acknowledgement  of my suggestion.  

Prof Duckett was of the opinion that things had got a lot worse since the 1997 Aged Care Act, John Howard’s work, which created ‘a business opportunity’   Prior to this there was a system called CAMSAM which was two modules; Care Aggregated Module and Standard Aggregated Module.  These were funded separately.  If they did not spend their Care money it was forfeited, so they could only profit on Services.

After 1997 there was no distinction so profits could be made from either component, so the quality of care declined, usually with lower staffing levels.

Some private-for-profit nursing homes have good care, but this is not common.  Some not-for-profits also had very poor care, but the general rule is that the standard of care relates to the number and training of staff.  The low wages (approximately equals $20 per hour) mean that the staff need to work multiple jobs in multiple locations which is what spread the COVID epidemic in Melbourne.  Government run homes tended to have better staffing ratios, so were better able to act against the infection.

 Professor Joseph Ibrahim commented that the terms of reference of the current Royal Commission on Aged Care were very narrow, only covering 5 years, and could not lead to prosecution.  He felt that this was deliberate.   The issues of overprescribing and assault have come up often.

He felt that this meant that it’s conclusions might be weaker and then not implemented, with a tendency to kick difficult problems down the road.

The commissioners themselves were of interest:

Richard Tracey had died before the enquiry started

Another, a Western Australian prosecutor had opted out (an unusual action as being on a Royal Commission is normally a good career move).

The two final commissioners are:

  1. Tony Pagoni,  Chairman- a retired judge who had had a specialisation in tax law and
  2. Lynette Briggs- a career health bureaucrat

Commissioner, Briggs has put out a report asking that aged care be returned to the control of the health department.  Prof Ibrahim comments that is very unusual for one Commissioner to make a public statement before the final report and this indicates that the commissioners are not in agreement.

Currently there are about 250,000 care workers and about 200,000 Professionals.  The care workers need six weeks training at a TAFE level to get a ‘Certificate 3’  About 1/3 are new migrants. They are paid about $20 per hour and casualised to decrease staff costs. The unions are worried that the new RECP (Regional Comprehensive Economic Partnership) trade treaty actually allows trade in people and that more visas for cheap labour in these areas will not help residents or local jobs.

The $20 billion dollar industry is founded approximately $14.5 billion from government, $4 billion from RADS and $2-4 billion for additional services. 

There are not-for-profits, but the large for-profit providers have increased since the 1977 act and are largely highly profitable big corporations, some multinational like BUPA.

 Professor Ibrahim is concerned that there is a lack of supervision.

There are no forensic accountants looking at what it costs to run an aged care facility and this has allowed supernormal profits by big players.  Money has been spent poorly or ‘hived off’. Obviously if the government runs some homes themselves there will be public service experience.

Prof Ibrahim believes that the future directions of aged care will be set by the multinational for-profit providers because these are the people who have direct access to the government. There is no significant advocacy for aged care residents.  He contrasts this with breast cancer advocates who pressed for less radical operations, and for Gay men who pressed for more enlightened AIDS/HIV policies. 

There have been discussions of ‘quality-of-life’ that have tended to be spoken of as needing less healthcare, but quality of life cannot be good without good health care.

The aged care industry likes home care as it lessens their costs and also pushes the liability back onto GPs.  A sense of proportion is necessary:

There are 2.5 million well older people and 200,000 in aged care.

             More radical treatments are now done in older age groups such as dialysis or cardiac surgery in the over 90s, very is some debate over this period some would say that it is a just to deny routine treatments but there is some distortion of priorities by having these lucrative procedures as fee-for-service, and there is also some inequity.

Since the development of antibiotics, medicines are seen as curative, but in fact they should be seen as being in three classes:

1. Curative 

2. Palliative

3. Preventative

There is quite a lot of cost-ineffective medication use, such as for osteoporosis. 

Solutions. (These are not just from the presenters)

  1. A national registration system for all levels of care workers period this should include people who do home help with shopping cleaning and gardening as well as Medical & personal care workers.
  2. Existing TAFE courses should be recognised but more courses will be needed.
  3. There needs to be a feedback database for complaints/praises and ratings as there is for AirBNB, restaurants etc.  The feedback database needs to be actively monitored by the regulator to follow up complaints or untoward events. 
  4. There needs to be a regulation system with accreditation and regular random inspections of facilities and surveys of residence.
  5. Academic researchers such as AIHW (Aust. Institute of Health and Welfare) should be at arm’s length and should have long-term commissions to do longitudinal studies of aged welfare and satisfaction so that individuals cannot be targeted if they state that they are not happy with the care in their institutions. 
  6. This should be combined with health research.
  7. There should be formal structured feedback systems with residents’ groups having paid advocacy groups and formal places and rights on regulatory bodies.
  8. There must be minimum wages and conditions for all workers and minimum staffing standards.
  9.  The Regulatory body must have a policing function, supervising staffing and wage levels and food and care standards

Final Comment

Note there are a large number of public submissions on the Royal Commission website, many of which make discouraging reading.  The privatisation seems to have led to profit-seeking rather than an improvement in care, and the  political forces seem likely to continue this.

http://agedcare.royalcommission.gov.au

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