Let’s not waste this critical opportunity for aged care reform, writes Professor Briony Dow.
A huge amount of work has gone into this royal commission, not only by people who came forward with stories of their lived experience but by the commissioners, legal counsel and many Australian Ageing Agenda readers who provided evidence and prepared thoughtful submissions.
With a massive 10,500 submissions and 640 witnesses, it is critically important this work, financial investment and emotional energy is not wasted. The emphasis of the recommendations on an entitlement approach to aged care is overdue.
All older Australians deserve access to high quality care that respects their dignity and preferences. It should encompass the right to freedom from abuse and neglect, and the right to make informed choices about their care, regardless of where they live.
Many people with lived experience have told their stories and the picture that emerges is not a positive one. Residential care is currently seen as the worst possible outcome for our older years and the Royal Commission into Aged Care Quality and Safety report reinforces this view. We need to establish trust in the aged care system.
Quality of care
The National Ageing Research Institute’s (NARI) research, commissioned by the royal commission, examined quality of care, quality of life and issues of sub-standard care in residential and community aged care.
One in three people in residential care reported their care needs were only sometimes met, and at least three in every five respondents had one or more main concerns either directly or indirectly indicative of substandard care.
Concerns included staff (47 per cent), fees and services (40 per cent), medical care (36 per cent), dignity and respect (24 per cent), rooms (24 per cent), lack of choice (18 per cent), personal care (17 per cent) and the facility (16 per cent).
Almost half (47 per cent) of these concerns were not shared with anyone. Less than a quarter of residents knew how to lodge a complaint, were comfortable doing so and certain action would be taken. This is unacceptable.
It is critically important government carefully considers the commissioners’ many recommendations for change including the appointment of a complaints commissioner in the quality regulator, a single comprehensive assessment process and a star-rating performance system to allow comparison of services.
NARI’s research provides an evidence-base for the commissioners’ comments and concerns about quality of care, and could be benchmarked to monitor the progress of promised reforms over time.
Among other concerns, the royal commission reported substandard clinical care and failure to facilitate or coordinate care to meet the complex care needs of people living in residential aged care homes.
Hence, many of the recommendations in the report focus on the need for changes to systems, processes and structures to guarantee universal access to the supports and services that an older person is assessed as needing, including clinical care. It is also clear the mandated number of minutes of care per day including minimum provision of nursing care is a critical element of improving care quality.
The recommendations regarding improvements to the workforce training, remuneration and professionalisation are welcome. They will go a long way to achieving the outcomes in the report A Matter of Care, which has been widely accepted as a solid blueprint for aged care workforce reform.
Fundamental workforce reforms in dementia care are needed to ensure a properly skilled, adequately remunerated workforce. Recognition of dementia care being core business for aged care is an important step towards greater equity of access to quality care for people with dementia.
We call for action that takes us beyond blaming and shaming the workforce who are often just trying to do the best they can in a system of care that is broken. Many aged care staff have felt the brunt of the community’s anger, and many migrant aged care workers have experienced further prejudice and racism as a result.
It is encouraging to see matters of cultural diversity woven throughout the recommendations. This marks a shift from pigeonholing diversity to integrating it across the aged care system, in light of the growing cultural diversity of Australia’s older population and aged care workforce.
We concurrently acknowledge that the diffusion of diversity may become a pretext to ignore it. This should not happen. Rather, tackling diversity provides us with an opportunity to think differently, link aged care to community empowerment and social development and develop models that are world leading.
Aged care for Aboriginal and Torres Strait Islander people
Based on our research with Aboriginal and Torres Strait Islander partners, we welcome the flexible approach to funding aged care services for Aboriginal and Torres Strait Islander people, especially those from remote communities. We also welcome training in cultural safety and trauma informed care, and funding for culturally important activities such as travel to and from Country.
Integration of care
The commissioners rightly identify that many concerns raised by older people and their carers during the commission relate not only to the aged care system, but also to lack of integration with health systems.
We welcome recommendations about increased integration between health and aged care systems including better access to allied health and primary care.
The current aged care system places the onus on older people or their family members to understand their aged care options and choose the best provider. Unfortunately, many older people do not feel empowered about making these decisions and can feel trapped in relationships with unsatisfactory services.
Our report for the royal commission, Models of Integrated Care, Health and Housing, highlighted the benefits of having qualified care coordinators who work at the interface between primary health, specialist care, and aged care. These workers can visit older people and their carers in their own homes, remain attentive to changing needs, offer advocacy and guidance, and ensure divisions between these systems do not result in unmet need or gaps in their care.
It is possible that the recommendation for the engagement of government funded care finders to assist older people with information about the aged care system and to provide case management services may address these problems, but it would be preferable to have a system that did not require specialist navigators.
Research and education
A chapter of the royal commission’s final report is devoted to research. NARI supports the recommendation for establishment of an aged care research council as there is an important role for research to drive best practice in the sector.
As both commissioners recommend, research should be co-designed with older people, industry partners, and government to ensure it is practical and meets their needs and priorities.
Co-designing research with older people, carers and healthcare workers is a core tenant of NARI’s human rights approach, and should be an essential part of the business of all ageing and aged care research. This approach should also underpin the reform process as a whole. The perspectives of current and future users of aged care should be central in designing the new aged care system.
NARI encourages the government and providers to consider research and teaching as core business for aged care. Without research-trained staff embedded in aged care settings, mentoring and modelling the translation of research into practice, the sector may continue to view research and teaching as separate from its main business, and fail to benefit from the latest innovations in practice.
Funding for aged care research is noted in the report as lacking. NARI endorses the recommendation for a new aged care research and innovation fund to lead and coordinate work on new models of care and innovations.
Given the clear need for reform and the extent of investment both financial and emotional that has gone in to producing this report, we call on the government to act swiftly and comprehensively to capitalise on this once-in-a-generation opportunity to design and provide a fit-for-purpose aged care system of which all Australians can be proud.
Professor Briony Dow is director of the National Ageing Research Institute.
This article appears in the current edition of Australian Ageing Agenda magazine (Mar-Apr).