Aged Care RC falls short on meaningful reform

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After two years of often harrowing evidence from 450 witnesses and 10,000 submissions, the Royal Commission’s multi-page report has fallen short on a clear path to lasting and meaningful reform.

Main image: A rearview shot of a senior woman sitting in a wheelchair (Shapecharge/Getty Images)

First, the report failed to spell out how much its reforms will cost, only that aged care will be more expensive than the predictions made in any of the multiple intergenerational reports before it. This inability to provide a proper costing makes it difficult for society and government to assess what is financially viable and what is not.

Second, the report fails to deliver a clear consensus on a way forward. Commissioners Tony Pagone and Lynelle Briggs disagreed on nearly a third of their recommendations, most notably on governance and funding.

Pagone recommends an Independent Commission model; Briggs favours a Government Leadership one.

Pagone’s model would end what he sees as a concentration of powers and functions in the Department of Health and its minister, and suggests creating a new independent statutory body. Briggs disagrees with Pagone on both his premise and his solution, arguing for a ‘new, enriched role for government.

And then, of course, there’s the huge issue of funding.

 

‘I fear that society as a whole undervalues older people and their contribution. The acceptance of poorer service provision in aged care reflects an undervaluing of the worth of older people, assumptions and stereotypes of older people and their capabilities, and ageism towards them.’

 

Sustainable funding, and making it politically acceptable, is critical to the success of any nation-building reform. Senior government ministers were hoping for a clear recommendation on that, but it never came.

Briggs wants a 1 per cent Medicare levy increase, branded as aged care improvement, and which will be tipped into consolidated revenue. Pagone punted on the possibility of a ‘hypothecated levy’ to the Productivity Commission for their consideration.

These two divergent approaches don’t give much political cover to politicians looking for ways to fund the reform.

It is no surprise then that Treasurer Josh Frydenberg immediately played down any prospect of a new tax: ‘I notice that the Commissioners had different approaches with respect to the levy or the tax proposals, but it is fair to say our government’s track record has been about delivering lower taxes.’

This is not to devalue its contribution, but merely acknowledge that it has failed to meet some of the more difficult challenges put to itthat it reach consensus on a pathway forward, that it work out how much it might cost, that it find a way to fund it and that it make it as easy as possible for the government to adopt its recommendations. It has not done this.

Having said that, it is also important to recognise that the Commission has reached a range of important conclusions on the sector. Let’s look at three which are particularly interesting.

Firstly, the Commission confirms the ‘community will ultimately be responsible for bringing aged care into the light.

Commissioner Briggs soberly concludes: ‘I fear that society as a whole undervalues older people and their contribution. The acceptance of poorer service provision in aged care reflects an undervaluing of the worth of older people, assumptions and stereotypes of older people and their capabilities, and ageism towards them.’

It is a sad truth that as we grow older we become increasingly invisible. Older Australians recognise their increasing invisibility, whether in seeking service at the local cafe or simply making eye contact walking down the street. Think about itwhen was the last time you made eye contact with an older Australian walking down the street?

The macro consequence of this, of course, is that issues of critical importance to older Australians are unfairly ignored. As a community, we must proactively address ageism and make an effort to recognise older Australians and their needs.

 

'It is the community that must be encouraged to take responsibility for the care of its elderly.'

 

Catholic Health Australia has been involved in two public campaigns on aged care in the past year in order to address this issue. This includes CHA’s ‘Fight for Better Aged Care’ campaign in the Eden-Monaro by-election last year, as well as the Australian Aged Care Collaboration’s Time to Care about Aged Care campaign.

Both aim to encourage the community to bring aged care into the political discourse, that is, to make the concerns of the elderly visible. It is a recognition that only the community can drive change. It is the community that must be encouraged to take responsibility for the care of its elderly.

Secondly, the Commission has recognised the centrality of relationships to the provision of care. This should be obvious to most of usbut it’s interesting how the very human nature of care can be lost in arguments about policy reform and funding mechanisms. To this end, the Commission has explained, Aged care is all about people, and relationships are the foundation of all human engagement.

To achieve this, the Commission has recommended minimum quality and safety standards for staff time (200 minutes of care provided per resident per day by 2022, increasing to 215 minutes by 2024) as well as minimum qualifications for the personal care workforce. Unfortunately the Commission has also failed to address how one goes about ensuring that personal carers possess sufficient empathysomething critical to the development of strong relationships but not easily found or taught in the working population.  

Finally, little comment has been made on the Royal Commission’s recommendation that any new Aged Care Act must enshrine the rights of older people seeking or receiving aged care. This is a completely novel approach in the Australian context.

In this sense it has proposed a rights-based approach to aged care and has recommended that any new Act enshrines: the right to equitable access to care services; the right to exercise choice between available resources; the right to freedom from degrading treatment or abuse; the right to liberty; the right to autonomy; the right to fair and non-discriminatory treatment; and the right to voice opinions and make complaints.

These rights will no doubt raise care standards giving elderly Australians another avenue for redress.

One might also assume the implementation of such rights will mean that rights enforcing litigation will increase, and that what the courts think about how aged care should be delivered will need to be considered by providers in the future.

 

 

 

Pat GarciaPat Garcia is CEO of Catholic Health Australia

Main image: A rearview shot of a senior woman sitting in a wheelchair (Shapecharge/Getty Images)

Topic tags: Pat Garcia, aged care, RC, CHA

 

 

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I know this stanza of a Les Murray poem (Nursing Home) sums it up: "She sits holding hands/with an ancient woman/who calls her brother and George/as bees summarise the garden." The words encapsulate the love, the dignity, the commitment between two people in a particular setting. Harried staff don't have time, distant relatives have to travel, governments prioritise other things. It's a tragedy when two people do not experience Murray's words.
Pam | 16 March 2021


Dear Pat, Like you, I have been disappointed in the report for its lack of a clear plan. Although it recognises the central role of relationships and rights, we need some answers to the question politicians typically ask, ‘so what will I do now?’ I have already spoken in my letter published in the Canberra Times (August 32, p 10 2020) of my simple practical proposal some time ago. In part it read, ‘As we already know, despite our outbursts of concern, studies show that only about 50% of aged care residents get any regular visits. My proposal is that, when a person becomes an aged care resident, someone (probably a relative) must commit to joining that resident for a meal at the care agency once a week. If no one is available for this not unreasonable commitment, the agency should require payment (from the funding body, the agency or from a relative) to subsidize such a community visitor to do this regular visiting. The advantages of this would include ongoing community relationships for the residents, monitoring of meals in nursing homes so that they reach acceptable standards (probably not at the current average cost of $6 per day), and a guarantee that we would never again see aged care drop to the abysmal standard we have now’.
Jill Sutton | 16 March 2021


Aged care is not about money. It is about the value of a person. When we are fair dinkum about valuing people we find ways to support them, some of which will require money. Older people are ignored and 'the market' has taught us to increase that disregard. You cannot make a profit from aged care. You can't sell them much product. Helping people age at home is considerably more affordable. To manage that attitudes and values and relationships need to change. Communities need to become aged friendly. Few know how to do that. Other communities, particularly in rural areas need models, templates and assistance to develop relationships with all ages. And certainly there needs to be significant funding for age care training in the vocational area. Nah the government can't do it as they have demonstrated. Older people lack solidarity. They need powerful advocacy. We all need to review how we want to be treated as we age; unless we have other plans. Keeping people at home will require rebuilding relationships and the difficulty of maintaining relationships with people grieving the loss of their skills and faculties. This requires more than spending money. It requires the risk of extending compassion, and finding new treasures. And let's not fool ourselves that expending money on an expensive home suffices. Ask them if they want to live longer or die longer. It's not like sending a kid to a private boarding school 'cos they are a problem.
Michael D. Breen | 16 March 2021


Thanks to both Pam and Jill for your responses to Pat's article on Aged Care and the RC. I am glad to see your choice to avoid directing blame and shame as the way to improve the conditions of those in aged care. I think that an absence of empathy for those in ongoing need and urgent distress is growing among us in Australia. Is empathy a requirement for employment in aged care? Do staff learn empathy as a competency in their training? Harried carers deserve empathy also. Can institutions commit themselves to develop empathy as a reflective practice among administrative staff, carers, family members and friends of residents? As a young man in the 1960s, I recall that community groups such as the local parish St Vincent de Paul Society organised their members to visit in pairs the long term residents in homes for care. At their group meeting, the SVDP visitors would give an account of their visit, celebrating their finding the residents well and in good spirits or noting some emerging challenge to their health or welfare. This raised the awareness of other members, drawing on their experience to plan suitable future action. I realise that some situations now are likely to be more complex. Some families may not want outsiders to visit their family members in a care facility. Schools have Parents and Friends groups that support the learning and safeguard the wellbeing of students - and teachers too, I hope. What will it take to develop a culture and practice of empathy in public places of care and employment? What will it cost? How will we all benefit from that?
Alex Nelson | 16 March 2021


Thank you Alex for thinking about my proposal. I suppose some families may object to a stranger visiting their relative. In that case they would surely have chosen not to leave their relative in the care of a whole bunch of untrained nursing home staff who are strangers, or to arrange for regular visits themselves. I feel very strongly that no vulnerable person should be left in an aged care facility without the option of sharing a regular visit from one particular person. If they didn’t like a community visitor provided, they could have the option of explaining this and another person could be offered. I am wondering if Pat Garcia would consider implementing such a scheme in any of the facilities for which he is currently responsible. Such a commitment would flag a true concern to ‘enhance empathy in public places of care’ as Alex so aptly describes it.
Jill Sutton | 17 March 2021


Yes Pam, it is tragedy, and shameful, that such a huge proportion of the populace does not understand. Yes Jill, your proposal has merit from a practical perspective of caring more, but would be another administrative hurdle of unknown cost and it does not address the first interest of a resident; "s/he is not hearing me. Is this person here for me or some other reason?" And so a huge yes to Alex, how do we address the absence of empathy? It can't be legislated and how can it be a community (of Aged Care) standard when it is not demanded anywhere else as such. However, it is achievable as a competency because it can be learned. To my own consternation I became aware that way too often I have been so intent on cutting to the chase of what I thought was important that in moment I was not listening, my heart became somewhat deaf and blind to what I thought cared about, because my mind had other ideas. I've had to learn somethings about Mindfulness. I've also noticed our better hospitals are learning more about and in talking to many many Carers of the aged and/or infirm I've been able to discern dire tly and indirectly a common ground of empathy between all of us. It does not always end well but for me it did most of the time. Two things- my circumstance had a beautiful person in the middle of the bridge and her best care depended on my advocacy because she had lost the cognitive abilities to do it herself. She had not lost the cognitive ability to discern for herself - who cares. For those that had ears and eyes to comprehend, the love between my best friend and wife was palpable. And the those that didn't get it had a LCD of higher education, higher responsibility, and higher expectations of themselves. Unfortunately it seems that the first expectations of compassion, empathy and humility were not present. I put it down to a professional hubris that needs retraining in what it means to care. It is important that the readers of ES understand this because most fit the demographic that were unable to care compassionately about her. She's recently gone, so now I can write as a priority, about who cares. Carers tend to care because they more often not have a fundamental connection with the very basic gut level difficulties of life and their hearts and minds are fundamentally connected with their feet as wearily trudge from one low paying assignment to another, up to a few times severally per day. These are the working poor but they do not complain. Unless one listens. Compassion is two track, and so often their seems to only be room for one at time. Medical professionals are the hardest to get through to. Their training puts them at the apex of civilisation and any deviation to reconsider by a less formally educated is a step into a place they fear. A protection by appealing to a State Civil Administrative Tribunal is available but those mechanisms know little and care less about the nuances of what a caring humanity looks like. And so if a decision were to be thrown to the Public Advocate, one would expect a fair hearing, at last. But unfortunately the weight of previous misunderstanding is on the scale first and those listening are not the Public Advocate but an educated person making judgements about all words chosen and their tone which are desperately trying to be conveyed in order at least level the balance beam. Dear peers, for I am nothing more nor less, the crucial exercise of compassion in our systemic society has yet to be learned in the practice of caring about and for our people, of our humanity. Yes, we can learn. Michael Breen and Alex Nelson and have gone beyond the Royal Commission as they needed and perhaps as Pat Curio couldn't because he has stay on the page. As I did when making a complaint about a doctor's care within an institution. The complaint was not within the ambit of the enquiry. Nor has been any of the higher vitues associated with caring. We will need more than good luck to achieve universally what has been outstandingly achieved by a minority of hospitals. By the Grace of God, it may be.
mcook | 17 March 2021


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