Rejecting the ‘givens’ in aged care

Above: HammondCare Chief Executive, Dr Stephen Judd giving his keynote address at the HammondCare conference 2011 last week. 

By Keryn Curtis

A new, rehabilitated residential aged care should focus on giving clients rehabilitation for functional improvement; should offer both permanent and short-term stays; should see active engagement of primary care, allied health and specialist medical practitioners; and should shed the protective disciplinary culture that restricts residents’ enjoyment of their latter years.

These are just some of the challenges that must be met if Australia’s aged care system is to meet the needs of future consumers, according to HammondCare Chief Executive, Dr Stephen Judd, speaking at the HammondCare Aged Care Conference 2011 in Sydney last week. 

While acknowledging that, by many international comparisons, “Australia’s system stacks up pretty well”, Dr Judd argued in his keynote address at this year’s HammondCare conference, that “we are not caring for older people as well as we could.  We have the capacity, if we have the will, to have the best aged care system in the world.”

In his address, Dr Judd, attacked some of the most fundamental underpinnings of residential aged care policy and service provision to support his argument that aged care in Australia is in desperate need of rehabilitation.

Channeling former British Prime Minister, Tony Blair, in his 2010 political memoir, ‘A Journey’, Dr Judd said that in order for aged care in Australia to be truly rehabilitated, there was a need to challenge a number of ‘givens’.

‘Givens’, he quoted from Blair, were ‘boundaries of thought and practice’. “A whole web of custom, practice and interest has been created around these ‘givens’,” he said.  “And in order to make progress, they must be changed.  If we don’t challenge the ‘givens’ of aged care we can never rehabilitate it.  This is not tinkering at the edges: this is thorough rehabilitation.”

Dr Judd went on to set out six givens which for argument’s sake, he had restricted to the system of ‘residential aged care’.

Total and permanent

Given number one, he said, is that residential aged care is permanent and long term.

“The idea of permanency is embedded in the Aged Care Act and it undergirds everything from the admission structures, to security of tenure to the financial structures,” he said. “This permanency ‘given’ is embedded in our thinking and our language about a resident’s home, even embedded in our expected outcomes for accreditation where these concepts, good in themselves, are endorsed.”

“Because aged care has become principally a ‘permanent’ experience, it has become a permanent and long term cost to the Government, and that is one reason we have the ‘gate-keeping’ Aged Care Assessment Team to do an assessment, and the wait for that can be lengthy,” he said.

“Residents are not going back to their home in the community:  this is a permanent move and it is for longer-term care. All of the financial incentives are to encourage permanent residents. Many service providers would have liquidity issues if this ‘given’ changed.”

The second ‘given’, according to Dr Judd, is that residential aged care is about nursing and personal care – and not about allied health.

“More than 93 per cent of the residential aged care workforce is either registered or enrolled nurses or personal carers.  Of the remainder, there are recreational activity officers and DTs.  The number of tertiary qualified allied health services – physiotherapy, occupational therapy, speech pathology, dietician, exercise physiology, social work and psychology– that are present within residential aged care is pretty small.”

Dr Judd pointed out that within ACFI, the only area that therapy features is in complex pain management.  “OTs are rarely seen and many professional physio services are delivered by private practitioners who come to the service and deliver sessions for which they are paid ‘sessional fees’.” 

“The focus is rarely on ongoing functional goals and has often become ‘massage rounds’ in order to claim within the CHC domain of ACFI. Whilst ACFI is good in that it captures ‘needs’, there is now less incentive to improve function. So therapy focused on improving mobility, for example, while adding value for a resident, is effectively unfunded. It is a monochrome offering with minimal active rehabilitation.”

The third ‘given’, according to Dr Judd, is the system’s dependency on a single-source government subsidy.

“While there is dependence on a single source of government subsidy in aged care, the finances will always constrain adequate service delivery. Yet the Australian Government wishes to maintain this fiction that says that government subsidies adequately provide in all cases for the care needs of all Australians in residential aged care.”

“I am not here to bag the Australian Government and its subsidising of aged care. I do not subscribe to the idea that all aged care needs must be met by Government: that’s Magic Pudding stuff.  But the idea that the nursing and personal care staffing levels in all services is the same nationwide is simply fanciful. 

“This ‘given’ – that a single source government subsidy is the primary source of income and is adequate for the level of care provided – needs to be challenged,” he said.

Workforce givens

The limited opportunity for career development within residential aged care was the fourth ‘given’ that Dr Judd said needed to be challenged.

“Much of the discussion about workforce issues in aged care refers to training, talks about hours, talks about the ageing of that workforce. But there is little comment on the limited career opportunities.” 

“You can join as a PCA but there is no obvious career path to follow and that needs to be addressed if we are to attract and retain experienced workers. We need to get better at internally selecting, contracting and better remunerating our ‘star’ care-workers.   We would love to clone them, so we must have them mentoring newcomers.    

“And we need to communicate this career opportunity so staff know that there are these benefits.  Some people will say we can’t afford it but with attrition rates so high, particularly in the first year, anything like this that reduces attrition, we can’t afford not to do!”

The fifth ‘given’, according to Dr Judd, is the notion that medical services in aged care are provided by the local visiting GP.

“GPs have been the backbone of medical services in residential aged care for the past 100 years but their availability to visit facilities isn’t getting any better and there are even fewer visits by specialists,” said Dr Judd.

Dr Judd said the difficulty in accessing timely and appropriate medical care resulted in a high rate of unnecessary hospital admissions and that a new medical care model, with new, innovative roles, was needed.

“It is time that service providers took the initiative to improve the breadth, depth and timeliness of medical services in residential aged care facilities.”

“Should we be engaging Medicare directly, analysing what the sessional cost of primary care is at our residential services and agreeing a fixed rate to support salaried positions?  

Dr Judd said that primary and specialist medical services must be engaged in different ways.  For example, establishing clinics on the larger aged care campuses with both GPs and specialists and nurse practitioners seeing patients; joint ventures with Medicare Locals to deliver round-the-clock primary care within residential services; and job-sharing salaried positions for those doctors who have other responsibilities.    

“It is through these initiatives that we will improve the delivery and presence and depth of medical care within residential aged care which, in turn, will improve clinical care overall.  

“The days of a service provider being responsible to provide medical services but being at the mercy of the overworked and tired local GP to show up to do it, is simply unsustainable today.   It must be supplanted with new, more vigorous and robust models, which improves the assurance of care for all residents.” 

Culture of Protectionism

The final ‘given’ on Dr Judd’s list was what he referred to as aged care’s “protective disciplinary culture”. 

“An elderly person in their own home has the right to drink and eat what they want, get fat, even have sex if they want,” he said. “But the moment they enter the aged care system they lose these basic rights and become captive in a controlled environment where they are ‘protectively disciplined’ for their own good, for their own health.”  

“It’s for the peace of mind of their relative, to pass the scrutinizing eye of the regulator, to avoid the complaint from the uptight relative.   But the result is that the person feels they do not belong, do not feel in control and have a diminished quality of life.”.

Dr Judd identified food safety regulation as a major area of concern, saying that in aged care, people are frequently denied many of the foods they have always enjoyed.  Certain cold meats, pates, soft cheeses, soft boiled eggs, fresh cut fruit and vegetables and soft-serve ice-cream for example, can be left off the menu because of the difficulty in making them comply with excessive food safety regulations for ‘vulnerable’ populations. 

“What happens is that the fear of non-compliance often drives service providers to take the easy route: to provide plastic cheese slices instead of real cheese; to drop rockmelon from the menu, or even to stop having salads for goodness sake!”

“We need to say, enough is enough,” said Dr Judd. “We cannot tolerate this protective regulatory stupidity any longer.” 

To help address this problem, he said HammondCare was taking two key steps.  Firstly it was engaging its own senior food safety consultant to ensure Hammond indeed has safe systems, but also to help ensure that food safety inspectors adhere to the actual regulations and not their own interpretation of them.   

Dr Judd said he had also asked Associate Prof Chris Poulos, Hammond Chair of Positive Ageing and Care, to start to put together a team to commence research on the real and actual risks of these ‘so called’ high risk foods.

“What has been the incidence of food-borne diseases in residential aged care?

“What have been the consequential impacts on older persons’ health as a result of food regulations – for example, the use of chlorine for bleaching; and what are the best ways to address the risks that are demonstrated by evidence, while still ensuring that residents can enjoy an enriched food culture,” he said.

He said he hoped the Food Authority of NSW, Food Standards Australia and NZ and the responsible State and Federal Ministers would welcome this evidence based approach.

“I will be disappointed if they are not up for it.  By the way, does anyone know how many reports of listeria there are in Australia each year?  About 60.  There are more reports of typhoid!”

“Aged care needs rehabilitating or it will collapse under its own weight,” said Dr Judd.

“We need an aged care future that we can aspire to and work towards.  Let’s start challenging the ‘givens’ so that we can start rehabilitating aged care – and let’s do it now!”