Aged Care…the journey to the present: Where to now?

The cover of the Royal Commission into Aged Care Quality and Safety interim report titled Neglect.

The dire problems of Aged Care have been much in the news over the past five years and especially since the arrival of the COVID Pandemic which exposed the failings in every aspect of a system which clearly is dysfunctional, cruel in its failures, being no longer fit for purpose, and in need of a major overhaul of regulation, funding, and accountability.

What would I know?

I am a registered nurse who has spent 43 years working mostly in the Victorian public health system as a direct care clinical nurse working in surgical, medical, respiratory, paediatric, and palliative care specialties

It was my time working in private aged care and my experience as a family member of two elderly relatives in residential aged care that have galvanised my desire to see change in a system that has progressively become more dysfunctional over 30 years.

Living longer

Over some 50 years modern medicine, vaccinations, and better nutrition have resulted in people living between 7-14 years longer than a century ago. The fortunate are able to maintain a good quality of life and live independently with minimal supports from family, friends, and neighbours. Eventually, genetic ageing causes some cognitive and physical decline, which for the less fortunate, whether by slow decline or sudden catastrophic event, causes them to no longer be able to live without major domestic supports and necessitates supported residential accommodation until their eventual demise.

Government responsibility 

At Federation in 1901, only a very few people reached “retirement age”. Elders mostly remained in their family groups cared for by daughters, aunts, and females in their extended families. Over the last century, pensions and aged care became a federal government responsibility.

Australia did not have an Institute of Demographic Studies until 1974, so government social planning was at best haphazard and piecemeal as part of election campaigns. By the late 1980’s it was realised that the post World War 2 baby boom and migrant influx would create a large 65+ ageing population, estimated to increase from 5.7% to some 11.7% by 2020. Population projections suggest there will be four million people aged between 64-84 by 2022. By 2030, 1 in 5 Australians will be aged over 65 and will comprise some 5.7 million people (ABS)

Quick history on aged care homes 

Aged care facilities previously consisted of hostels for seniors needing low care assistance and “Nursing Homes” for more frail high care residents with mobility impairment, high care morbidities and cognitive decline including dementia. Most were staffed by a combination of registered nurses and nursing aides or enrolled nurses.

Most facilities were community-run and funded or started by not-for-profit religious and philanthropic groups. Most states had state-funded “aftercare” facilities which gradually morphed into long-term residential “nursing homes” which provided stop-gap accommodation until permanent nursing home placements could be found.

By 1996 the increased resident age and frailty and increased costs of higher acuity care brought about a review of aged care regulation, funding, and staffing costs. Funding models based on care dependency were seen as complicated and expensive. On top of this, many multi-occupancy room buildings were not fit for purpose and needed replacing.

The Howard Federal Government of the day resolved to encourage private for-profit corporate entities to invest in new aged care properties. They did this by building new modern buildings where a majority of residents would pay a bond plus private fees. A minority of up to 20% of places would be reserved as fully government-funded places for people of lesser means. Legislation “lite” would allow providers to create management efficiencies to enable profits and also to charge residents fees for extra services.

In highly simplified form, the effect of the 1997 Aged Care Act also placed a cap on funding of aged care, with the total expenditure set by the government at yearly budget reviews.

Over time, some private and not-for-profit providers struggled to keep their business operations solvent and, in the case of the corporates, profitable.

Cutting the nursing out of nursing homes

Whereas once nurses in aged care facilities were paid more or less equal wages with the acute sector, post 1997, wages did not keep up with their peers in the public and private hospital sector. Nurses were gradually replaced with personal care attendants as staff retired, returned to the public sector, or were simply replaced as vacancies occurred.

The numbers of skilled qualified staff decreased as dependency increased.  Residents became older and sicker, with decreasing mobility. The number of cognitively impaired people in residential care is currently estimated at 50-70% of residents.

As in any organisation, the level of service is proportional to the quality of management, the staffing levels, and the skill, training, and expertise of those who do the work. As client needs increased, carer hours did not, and as nursing expertise and staffing decreased, the ability to care for the medical, emotional, cognitive, and pharmacological requirements of people nearing the end of life also became critically decimated.

Regulatory failings

With privatisation, the number of aged care facilities increased, while oversight of the Aged Care Act and residential care regulations declined. Management were routinely notified before regulatory inspections, so it was not possible to gauge the true state of care delivery. Nevertheless, ever more facilities failed care criteria at inspection. Despite growing outrage by families and the public at large, as well as several major press exposes of neglect, premature deaths and major instances of abuse, increased attempts at regulation continued to fail.

Despite several changes and revisions to the Act affecting residential facilities and, increasingly community services, demand and quality of care has not kept up with modern expectations of adequate, timely, and humane care delivery.

While the size of most private facilities increased from 30–40 beds to often 80–120 beds most are now staffed by only one registered nurse, along with a few enrolled nurses and mostly unregulated, unregistered carers. Managers often have no nursing or allied health training.

The Aged Care Royal Commission 

There have been 18 inquiries and a recent Royal Commission into Aged Care Quality and Safety which have all confirmed the many stories of dysfunction, declining standards of care, neglect, and abuse. Findings report a total failure of a system with impossible workloads which fails to care for older Australians.  Most care staff work part-time hours and are overworked, underpaid, and overwhelmed. Many are employed as casual shift workers. 

Thousands of submissions and 18 months of nationwide hearings produced an interim report titled ” Neglect” and a damning final report recommending 148 major reforms including a restructure of the governance, accountability, and funding of the entire aged care system.

Let’s not miss the opportunity for reform

Disappointingly the incumbent Federal Government seems hell-bent on cherry-picking a much lesser course of action to that recommended in the strongest terms by the Royal Commissioners. The power of the final report was watered down as the commissioners diverge on a number of issues enabling government to pick and choose.

So we, who have been bystanders to the misery and distress of the loved ones placed in the care of this horrendously dysfunctional system, have determined that we will fight to negotiate a better, fairer outcome for older Australians using aged care services in the future.

Those Australians who worked hard to make this country what it is today, deserve to enjoy their human right of a peaceful, dignified and fulfilling end of life. We owe them that much.

We have the answers, we have the expertise, the people have the will. We need to insist on a new, comprehensive Human Rights based Aged Care Act which will ensure transparency, accountability and provide care less beholden to political whim.

It will take those we have entrusted with the governance of the nation’s financial means, public service, and legislative power to make it happen.

Denying the elders of a first-world democracy their rights is inexcusable, unethical. The time is NOW.

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