Aged Care in Australia
A television documentary entitled The End of the Line, an ABC Four Corners program, was aired on 1 June 2009. A number of you may have seen it, but I would like to review the shocking situation it dealt with for the benefit of those who did not see it, because it affects people you have known, and eventually maybe even yourself, or your loved ones in the future.
There are currently 170,000 elderly Australians living in nursing homes around the country with up to 70% of them in the ‘high care’ category. This is what used to be called “nursing home care”. Most residents are women, because women live longer than men in most western societies. Currently, those aged 80 or over, who are the people most likely to require assistance, make up 3% of the population and this is expected to climb to 6% of the population in 2031 (Australian Bureau of Statistics).
The need for high care residential places (nursing homes) outstrips the current supply, however, and there is nowhere else for them to go. So the people with high needs go into the regular care places, which are simply not equipped medically, or otherwise to deal with their complex problems.
The frail elderly are some of the most vulnerable people in our community, along with infants and the severely disabled, who are completely dependent on others for their survival, comfort and all personal care. Some of the centres that have been set up to look after them are not coping with the responsibility they have. The resulting sheer human misery, day after day, is devastating and disgraceful.
An independent survey of 700 not for profit and private operators released by a leading accounting firm showed that those who’d built new facilities with single bed rooms and ensuites were averaging annual returns of only 1.1 per cent on their investment, and some were operating at a loss. This loss can only be covered by donations from churches and from fund-raising. The for-profit operators charge higher fees, and sometimes cut corners in care to lower costs. There is little incentive for either group to upgrade facilities or build new properties, but the population of the aged is set to increase dramatically with the ‘Baby Boomer’ generation retiring. The capital costs for new high-care centres can only come from the Federal Government for the for-profit companies will not invest in buildings that cannot produce a return on capital invested, and the not for profit charitable and churched based organizations, have been spending their reserves on providing nursing care and to cover operating losses.
It is the responsibility of the Federal Government to determine the number of beds available as well as the setting the fees any operator can charge. Currently nursing homes get $138 subsidy per day from the Government for every high care resident in a single ensuite room, added to the resident’s contribution of $32 per day. The nursing homes cannot charge any more beyond that, despite the ongoing increase in the cost of fuel, wages, groceries, and basic supplies. That $170 per day per person has to cover all costs of running the home, including administration, accommodation, three full meals plus morning and afternoon tea, nursing care, cleaning services, etc, and the cost of registered nurses on three shifts for every day of the year, every hour of the day. Even a quick calculation makes it obvious that something in the system has to give.
Family, friends and residents themselves have made many complaints to the agencies ostensibly set up to do so. All resulting reports and investigations have shown the same thing, that these institutions have many problems basically due to underfunding which leads to understaffing and inability to deliver services to the level expected by the community.
Some of the most concerning problems are: they are so low on staff that even regular patient care is being compromised, much less those with high care needs; having to do things so cheaply that there is not enough staff time, not enough equipment, linens, etc to ensure proper care; residents have been injured or developed pneumonia or pressure sores and not been provided adequate medical treatment; family has requested a physician’s care but it has not been received; people are shouted at by frustrated staff, or treated in a disrespectful manner; family members are not given full information about the health status of their relatives in care, nor able to access their medical records even if they hold power of attorney or are executors of the will.
People hired to work at aged care facilities as cleaners and domestic staff are often untrained, unskilled, low paid, working irregular and unpopular hours, recent migrants non-fluent in English communication. They earn about 20% less than nurses in State hospitals and much less than in private hospitals and in other settings. Naturally the staff with better skills go elsewhere. The nurses that stay report being broken hearted and utterly burned out by coping with an overwhelming workload, and being expected to supervise incompetent, inexperienced nurses aides who have had only one day’s training before being unloosed on the vulnerable aged.
Most appallingly of all, unlike in childcare facilities, there is no minimum nurse to patient ratio requirement. That sets up a situation with 120 residents and 1 registered nurse on site who is responsible for their medication, oversight of toileting and personal care for all of them. Assisting 120 people with proper toileting procedure alone would require more than one person working non-stop for their whole shift.
This leads to unwiped bottoms, medications not taken, beds left wet with urine around the patient, meals and liquids left unfed to hungry people unable to feed themselves, and a severely stressed staff. This cannot be allowed to continue.
The Chairman of the Australian Medical Association Committee for Healthy Ageing has called for the standards that govern aged care facilities to be rewritten to ensure residents receive proper access to doctors, “There needs to be an adequate number of appropriately skilled nurses in aged care homes to ensure that residents who require medical attention from a doctor are identified quickly. Every elderly person in Australia deserves a right to medical care, regardless of whether they are in their own home or in a nursing home.”
The Commonwealth set up the Aged Care Complaints Investigation Scheme, managed by the Office of Aged Care Quality and Compliance, to respond to all complaints about nursing homes but their apparent modus operandi, according to Professor Alan Pearson who was interviewed on the Four Corners program, is to discuss the issue with the accused nursing home, not the complainant; this results in eyewitness accounts of concerned visitors to the nursing homes in question being discounted completely and cases invariably finding no cause for complaint.
He explained that the Aged Care Complaints Investigation Scheme ‘is not an investigation scheme at all, but a bureaucratic procedure to check that the nursing homes are complying with Aged Care Standards in terms of their systems and processes. The system is not investigating complaints but compliance. It is basically paperwork about paperwork, which is what meets the bureaucratic requirements under the law.’
To give a concrete example: doses of dementia medications are so carefully calibrated that they must be given at the same time everyday to work properly, but with such pressures on staff it was impossible to meet such strict timelines – resulting in bad medical, emotional and social outcomes for the dementia sufferers who got very agitated and less easy to control. This is why only a registered nurse can handle medications, which means they are often unavailable to give oversight to other staff providing lower level care.
But in looking at the complaints that this is happening, the Investigation Scheme simply checked that there were measures in place that assured people got their medications on time, not that people actually got their medications on time. If the written policies existed that was enough for them.
There is another tier of responsibility involved, in that the Aged Care Commissioner can review and overturn the CIS decisions – but, unbelievably, her findings are not enforceable under the legislation as it stands.
Complaints from the public are not disclosed, so that consumers cannot assess such information when they are choosing a facility for a loved one. However, from the first of July 2009 there will be a new website about nursing homes according to Justine Elliott, the Minister for Ageing, which will at least have information about any sanctions that have been in place against any nursing home.
Dr Moyes believes the entire provision of Aged Care services needs to be re-examined, and supports a complete overhaul of the Aged Care Complaints Investigation Scheme’s purpose and focus – to be on real outcomes for people not just good paperwork. Our old people going into nursing homes expect and deserve so much more than they are actually getting, and people in the community need to pressure the government with the message that this situation needs remedying now