Old and Broken
What comes next for Aged Care?
Few things hit closer to home than the best way to care for our ageing population. 1.3 million Australians access aged care services each year, which means that millions of others are indirectly affected by the care that these services provide to ageing parents, family members or loved ones.
If you are middle aged, like us, it is likely that you often think about how you will care for your ageing parents. Or, if you are lucky enough to have grandparents still around, you are also concerned about their current care: Are they taking their medications correctly? Is their house clean? Are they lonely? Who is caring for them and are those people qualified? Am I doing enough to help? And unfortunately, how am I going to pay for all of this?
In Australia, like most western countries, we have adopted models of care for our older population that relies on seeking help for our loved ones outside the household and family structure. Obtaining help for our loved ones is one way for us to continue to be able to handle the demands of our everyday lives, jobs and younger members of the family.
But seeking external help comes at the cost of having to rely on - and trust - the system that has been built, to deliver the respectful, safe and highquality care that they expect and we wish for them. The types of services that ageing Australians most often use include home support – that helps with personal and home care activities so that they can stay in their own homes for as long as possible – or nursing home care once they can no longer live at home.
From the Australian Aged Care Act 1997 to a Royal Commission
More than 20 years have passed since the implementation of the Australian Aged Care Act in 1997. This year, on March 1st 2021, the Royal Commission into Aged Care Quality and Safety final report was delivered to the Australian Government and its citizens.
This Royal Commission, announced in September 2018 by the Honourable Scott Morrison, a mere 3 weeks after he became Prime Minister, happened after the culmination of a series of investigations, state senate inquiries, public outcries, and exposés of the troubles in the aged care sector.
There have been more than twenty investigations and recommendations made at both the state and federal levels regarding aged care services in the last 20+ years. Some of the major investigations were in response to reports of neglect and abuse, like the Review of the National Aged Care Quality
IN AUSTRALIA, LIKE MOST WESTERN COUNTRIES, WE HAVE ADOPTED MODELS OF CARE FOR OUR OLDER POPULATION THAT RELIES ON SEEKING HELP FOR OUR LOVED ONES OUTSIDE THE HOUSEHOLD AND FAMILY STRUCTURE.
Regulatory Processes, Carnell-paterson in 2017, which examined the failures of the Oakden facility in South Australia. This particular investigation resulted in recommendations regarding need for better clinical oversight of residents, compliance monitoring, complaints handling, and public reporting of facility performance.
While it led to the closure of the Oakden facility and re-housing of all its residents, greater system-wide changes have not necessarily resulted. Other investigations have affected the system more widely, including the Productivity Commission of 2011 (Caring for Older Australians) investigation, which resulted in the development and implementation of Myagedcare, the online system or ‘gateway' for accessing aged care services, and Consumer Directed Care for home care recipients, which put individuals in charge of their own funding for services.
Both of these investigations, and the many others, had common elements: the need for better standards of care, greater transparency, better access (for all Australians), and many others, all of which are heavily reliant on the need for a better overall governance structure.
What the other reviews also had in common was that they resulted in what can only be described as ad hoc tinkering around the edges rather than the wholesale restructuring of the system to allow it to grow and meet the expectations and needs of our ageing population.
But then came 2018, and who can forget the Four Corners episodes exposing the abuse some residents were enduring in certain aged care facilities? It was shameful, hurtful, and disconcerting for us all to watch. While the sensationalisation of the events depicted on these episodes were of debatable intent, it provided the necessary impetus for the Royal Commission.
There have been more than twenty investigations and recommendations made at both the state and federal levels regarding aged care services in the last 20+ years.
The Honourable Scott Morison and then Aged Care Minister Ken Wyatt announced the Royal Commission and tasked it with investigating and addressing the safety, quality, mistreatment and abuse in the aged care sector. It was also provisioned to investigate sustainable strategies to best meet the needs of older Australians, including younger people
Who can forget the Four Corners episodes exposing the abuse some residents were enduring in certain aged care facilities? It was shameful, hurtful, and disconcerting
10,500 submissions, 8 background investigations, 20 in-depth research projects, a special COVID-19 report, an interim report, 23 hearings/ workshops with 641 witnesses, and countless hours of work by an extremely dedicated team of Commissioners, Council Assisting, and general staff. In conclusion, the Commission delivered 148 recommendations and a five-volume final report
with disabilities, culturally and linguistic diverse communities, and Aboriginal people.
In November 2018, the Royal Commission terms of reference announced that it would address these issues, while accounting for the changing demographics of our population. Additionally, it would make recommendations that were sustainable. While not an easy feat, this was an amazing opportunity - to deliver recommendations with direct policy implications and social impact on an ever-increasing problem that touches all of us.
From the outset, the Royal Commission into Aged Care Quality and Safety was a unique Royal Commission. Firstly: its policy focus, in contrast to prior commissions that generally focused on wrongdoing, for example the Royal Commission into Misconduct in the Banking, Superannuation and Financial Services Industry.
Secondly: it appointed two Commissioners - Ms Lynelle Briggs AO and Honourable Richard Tracey AM - and one year into its investigations had to deal with the sudden passing of Commissioner Tracey and his replacement by the Honourable Tony Pagone QC.
And finally, about 18 months into its investigations, the COVID-19 pandemic began, disproportionately harming the very people the Commission was investigating.
The uniqueness of this Royal Commission didn't end there. The unexpected, but not unforeseeable, surprise of this Royal Commission were the diverging recommendations made by the Commissioners, included within the final report.
What did the Royal Commission deliver?
The Royal Commission included the impressive review of over 10,500 submissions, 8 background investigations, 20 in-depth research projects, a special COVID-19 report, an interim report, 23 hearings/workshops with 641 witnesses, and countless hours of work by an extremely dedicated team of Commissioners, Council Assisting, and general staff.
In conclusion, the Commission delivered 148 recommendations and a five-volume final report to
justify, explain, and direct these recommendations.
Some of these recommendations are undoubtedly ‘no-brainer-should-havebeen-done-ages-ago' actions like the need for quality indicators (recommendations 22, 23). You can't have ‘quality and safety' unless you define, measure, report, and improve on quality and safety.
Unfortunately, the majority of the recommendations made by the Royal Commission, are not so easy to implement, as they recommend (at times) a fundamental root-and-branch rethinking of the sector.
This begins with recommendations to redefine the purpose of the aged care system, with a new Aged Care Act. The Royal Commission goes so far as to recommend their own definition of the system, as one that “...ensure[s] that older people have an entitlement to high quality aged care and support and that they must receive it. Such care and support must be safe and timely and must assist older people to live an active, self-determined and meaningful life in a safe and caring environment that allows for dignified living in old age.”
This is the very least that every Australian should be expecting from the system.
And while their definition of a caring, supportive and dignified system can hardly be debated, not
ROSA has linked information from the aged care and health care sectors to understand the complete pathway of ageing for older Australians
Tony Pagone recommended that the sector should be led by an Independent Commission, independent from the Australian Government. This was a markedly different line to Commissioner Briggs who advocated reforming the system from within
all of the recommendations resulting from the Royal Commission were in such agreement. While the two Commissioners agreed that the sector no longer supported the needs of its primary stakeholders, the Commissioners diverged on the fundamental solutions to systemic problems.
As we entered chapter 2 of the recommendations – which are related to the governance of aged care services – the cracks between the report's authors start to show. On recommendation 5 through 11, the two Commissioners did not agree on fundamental issues regarding the structuring and governance of a reformed aged care system. In simple terms their disagreement came down to who would be in charge of governance of the sector, with major flow-on effects for the rest of the Commission's recommendations.
Honourable Tony Pagone recommended that the sector should be led by an Independent Commission, independent from the Australian
Government. This was a markedly different line to Commissioner Briggs who advocated reforming the system from within and maintaining the federal government's leadership of the sector. The latter, was the solution preferred by the Australian Government, as announced in their response to the Royal Commission's final report on May 11, 2021.
Although Commissioner Pagone prefaced the final report by saying that “our disagreement about the best way for improvement to be achieved is not a justification for doing nothing”, it remains to be seen whether this foundational disagreement will hinder the challenging and complex reforms required within the sector. It is easy to be cynical that such a divergence of ideas will ultimately dull the findings of this incredible piece of investigation.
Disagreements likewise arose on issues of how services should be funded and delivered, and how the workforce should be organised and supported. On the whole this added up to 25 out of 148 recommendations having disagreement, some of which were only slightly modified recommendation options or recommendations only supported by one Commissioner.
What’s next for all of us?
Complex problems have complex, and costly, solutions. Researchers have suggested that Royal Commissions are particularly useful for framing questions and problems and building support to address the issues raised by them.
The hopeful among us believe that the Royal Commission into Aged Care Quality and Safety has kept the spotlight on the significant issues with the sector, including unacceptable practices regarding use of physical and chemical restraint, wait lists, workforce and quality monitoring, as well as uncovering new issues surrounding individuals' willingness to actually pay for aged care entitlement nationally.
The Royal Commission has also mobilised aged care providers, health care providers, professional organisations, consumer representatives, and academics who will play roles on the implementation of the recommendations. At least in the short term, these organisations and individuals will be waiting anxiously for their chance to jump into the space opened up by this Commission to make much needed improvements to the system.
There is much work to be done: providing leadership for workforce training; creating new models of care; building the evidence-base that supports aged care providers to improve their standard of care; greater capacity for governmental departments to evaluate and monitor the performance of aged care providers, and empowering individuals to make informed choices about their care.
The Australian Government's formal response to the Royal Commission's final report announced on May 11, 2021, included a $17.7 billion package of support and a five-year, five pillar ‘Aged Care Reform Plan', described as a “once in a generation reform to aged care to deliver respect, care and dignity to our senior Australians.”
While the new funding measures are largely welcomed and are long overdue, the Government's response is not the fundamental systemwide reform that many were hoping for. The five pillars of
There is much work to be done: providing leadership for workforce training; creating new models of care; building the evidencebase that supports aged care providers to improve their standard of care; greater capacity for governmental departments to evaluate and monitor the performance of aged care providers, and empowering individuals
the ‘Aged Care Reform Plan' focuses on home care (supported by $7.5 billion), residential aged care services and sustainability ($7.8 billion), residential aged care quality and safety ($942 million), workforce ($652.1 million) and governance ($698.3 million).
Some parts of the plan still worry us. For example, the expansion of home care packages supporting older Australians to stay at home longer, included an additional 80,000 home care packages, with 40,000 to be released in 2021-22 and the remaining in 2022-23. However, with 96,859 people in Australia waiting for a home care package at their approved level at the present time, experts, critics, and advocates agree that this is less than what the Royal Commission's own work estimated would be necessary.
Another consideration is the workforce required to support these increased number of packages. Since 2017 the number of Australians receiving a home care package has doubled from 71,423 to 142,436 in 2020 but data from the most recent aged care workforce survey has shown the home care workforce may have decreased (2012 to 2016 numbers show a decrease of 13%).
Australians receiving a home care package has doubled from 71,423 to 142,436 in 2020 but data from the most recent aged care workforce survey has shown the home care workforce may have decreased
Workforce, also a pillar of the Government's Aged Care Reform, needs to address the shortage of qualified and skilled staff, however support for an increased 33,800 subsidised vocational training places is not scheduled to commence until 2022. Raising the question, of how will the care for these packages be provided?
The Australian Government and its people have more than enough evidence to demand that changes must be made to the currently broken system - and for the next four years an $17.7 billion investment to improve it. But at the moment, a detailed roadmap and
timeline outlining how the Government will implement these changes or the new recommended Aged Care Act are lacking, leaving the aged care industry, care workers, and the people seeking aged care services in limbo and without any clear path forward.
This means we still don't know how older Australians are going to get better access to aged care services, how long they will have to wait for a home care package, how an aged care facility in my neighborhood compares to another facility, and how they will be able to afford the care they deserve.
Unfortunately, only time will tell which recommendations will in fact be enacted by the Government and whether these will lead to the desperate improvements needed to create a caring, transparent, efficient, and accessible aged care system for Australia.
We certainly hope that one that we can all be proud of, is being designed.