The aged care royal commission has delivered a worthy vision that prompts some searching questions, write Stephen Teulan and Nikita Weickhardt.

The 148 recommendations of the Royal Commission into Aged Care Quality and Safety offer a chance for older Australians to enjoy better lives and better care. To understand where we go from here, it is vital to understand just what the Royal Commission has recommended.

The recommendations recognise the rights, needs and preferences of older people, their families and carers, and that these should be enshrined in a new Aged Care Act, which would also set out providers’ duty of care. Key to achieving this is transitioning from a rationing model to an entitlement model, with consumer choice of service modality based on a single assessment of need.

The Commissioners call for a fundamental redesign of support for older people in order to integrate aged care, health care, housing and welfare. As they put it, “the aged care system should put older people first and it should be equitable, effective, ambitious, accountable and sustainable”. To achieve that end, they propose an unprecedented breadth and scale of change in aged care policy over the next decade.

Improving the experience of older people, their families and carers

Navigating the aged care system can be challenging for older people, so the Commissioners recommend face-to-face “care finders” to support older people to navigate the system as well as improving information on services, including a “star ratings” system based on the quality regulator’s assessment.

The recommendations include developing tailored pathways of supports for people living with dementia and for Aboriginal and Torres Strait Islander people. Also recommended are for informal carers of older people to get improved recognition and access to supports, including respite. Older people with a disability would have supports equivalent to those provided through the National Disability Insurance Scheme to younger people with a disability.

Also addressed in the Commissioners’ report are the hurdles faced by many older people who prefer to receive care at home for as long as possible. After the current waiting lists are cleared, access to home care would be provided within 30 days of assessment. The funding in a home care package would be up to the highest level of care funding in residential care, and consumers would not have to contribute to the care they receive.

These recommendations would profoundly impact older people who currently face long waits or find the cost of those services unacceptable. The recommendations would rebalance aged care provision in Australia between home care and residential care.

For older Australians requiring residential aged care, the recommendations would facilitate a more personalised experience. They would involve smaller household models of care with required minimum staffing levels. There would be registration of all care staff, who would receive regulated training and hold mandated qualifications. Linkages to primary care, palliative care and acute care services would be enhanced, while allied health and dental care would be improved. The use of physical and chemical restraints would face greater controls. Residents would not be required to contribute to the care component of the services they receive, but other means-tested arrangements would apply.

Reshaping the provision of aged care supports

Aged care providers would be central to achieving these ambitions for older people and implementing many recommended improvements. They would face greater ongoing and annual reporting requirements in relation to care indicators, adverse events and performance, including compliance with staffing standards and the use of restraints. They would also be under increased scrutiny, with star ratings and strengthened prudential standards. Quality standards will be revised, and the quality regulator will have wider enforcement powers, including civil penalties for approved providers and directors.

Recommendations to enhance the financial sustainability of aged care providers include an immediate government-funded increase of $10 per day in residential aged care for each resident (linked to demonstrated levels of purchased goods, particularly food), and maintaining a higher level of viability supplements for rural and remote service providers.

The Commissioners also recommend improved indexation of subsidies, funding for education and training of staff, and increasing the level of capital grants. The future financial sustainability of providers would rest on the determinations of the recommended Independent Pricing Authority, which would set subsidies and user charges for the aged care system. These would be based on an analysis of the cost of providing care, including the additional costs incurred by regional, rural and remote services.

Setting higher expectations for the governance of the aged care system

There are other significant changes to the institutions that govern and regulate the aged care system that are proposed.

While Commissioners Tony Pagone and Lynelle Briggs disagreed on whether the governing body should be the Department of Health or an incorporated Australian Aged Care Commission, they agreed that the governing body should be far more active on key issues – planning for service access and management of the aged care market; system monitoring and reform; workforce planning; and setting and monitoring prudential standards – than the Department has previously been.

Under the recommendations, the Australian Commission on Safety and Quality in Health Care would revise the aged care quality standards and have ongoing responsibility for formulating quality and safety standards, guidelines and indicators for aged care. The Commissioners disagreed on where quality regulation should reside, with Commissioner Briggs recommending that a new independent Aged Care Quality and Safety Authority be established.

Also recommended was an Aged Care Research and Innovation Fund to promote research and innovation in aged care service delivery, ageing and ageing related conditions, and an Inspector-General of Aged Care should monitor and report on the administration and governance of the aged care system, including the performance of the system governor, the quality regulator, the prudential regulator and the pricing authority.

The sourcing of financing for the sector, including additional funding to achieve expanded and improved services, remains unclear. The Commissioners have not agreed whether the funding should be by current government budget allocation processes or by imposing a dedicated tax levy.

A worthy vision requires capability and maturity

Overall, the final report of the royal commission offers a transformational vision and plan for the support of older people, their families and carers. It is a worthy vision if Australia is to value older people.

Questions remain about which bodies would be responsible for the governance of a new aged care system and how it will be financed. Confidence in the financial sustainability of aged care providers, particularly residential aged care providers, depends on trust in the future determinations of an Independent Pricing Authority and in the required funding being secured.

Beyond those considerations is the question of whether the Federal Government and providers have the capability and maturity to implement the scale and breadth of change envisaged. If these recommendations are accepted by the Government, that assessment will be critical in deciding how the recommendations are sequenced and implemented so that older people can experience the care and support they deserve.

Stephen Teulan is a principal and Nikita Weickhardt is a director at Nous Group, an international management consultancy.

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