15/11/2020
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:
- Tony Pagoni, Chairman- a retired judge who had had a specialisation in tax law and
- 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)
- 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.
- Existing TAFE courses should be recognised but more courses will be needed.
- 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.
- There needs to be a regulation system with accreditation and regular random inspections of facilities and surveys of residence.
- 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.
- This should be combined with health research.
- There should be formal structured feedback systems with residents’ groups having paid advocacy groups and formal places and rights on regulatory bodies.
- There must be minimum wages and conditions for all workers and minimum staffing standards.
- 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.