Raising the Care Factor: Royal Commission into Aged Care
Dr Ayman Shenouda
There is hope that ensuring dignified support for people in aged care will be one step further with the announcement of a Royal Commission into Aged Care.
I certainly welcome this royal commission and see it as a key step forward in ensuring our patients get the right care, support, and dignity they deserve.
This not only provides hope for patients and their families but hope for those working in the sector and committed to providing consistent, quality care to their residents.
What have we learnt?
Most working in the sector would welcome the opportunity for real reform through a comprehensive consultation and review of this kind.
The issue certainly qualifies for such a focus but it’s not like there haven’t been any policy questions posed in this space in recent years.
The royal commission is just the latest in a very long line of inquiries in aged care. We’ve had years of review and countless recommendations with most now, it seems, awaiting web archive.
It has been reported in recent days that there have been 20 federal inquiries by the Senate and others into aged care since 2009.
Even the Aged Care Minister admitted to that only a few weeks out from this latest policy shift:
"…after two years and maybe $200 million being spent on it, it will come back with the same set or a very similar set of recommendations, the governments will respond and put into place similar bodies".
Let’s not forget the states who have also had a strong focus over many years and there’s plenty of positive state-driven change and too many to list here.
The point is that we know there are systemic national challenges in aged care and through significant review, we now have the policy answers.
Ensuring quality care
This Royal Commission certainly places a stronger lens on the issues but the areas of reform are already clear and this might just keep us in a constant policy cycle of inaction.
Having worked in aged care over many years it is as clear to me what needs to occur as it would be for most in the sector.
I should add that some of these facilities provide excellent care and this should not be lost in what will likely be a very intense and confronting royal commission.
One glaring omission from a more recent review - the Government’s Review of National Aged Care Quality Regulatory Processes – was a required focus on enabling a more collaborative patient-centred care model.
This model is reliant on adequate remuneration and unless this is prioritised residents in aged care will have their medical care compromised.
Ensuring a key role of general practice in aged care service provision is integral to the solution.
The review failed to acknowledge the critical role of GPs in improving the quality of care in these facilities and I wrote about it at that time.
It is these obvious service issues, central to ensuring quality, that continue to be ignored or held over for the next review.
What are the priorities?
A focus on quality has to look at ways to make improvements including through stronger staffing and appropriate skill mix levels.
We need to focus on different models of nursing home care that can support general practitioner decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from nursing homes.
Reducing unplanned admissions means we have to start dealing with those issues in the nursing home setting and with that requires appropriately funded infrastructure including adequate nurse support.
It is clear we need very different models of care than those currently funded in order to provide the complex support for those vulnerable to acute and deteriorating illness.
Currently, the role of the GP is clearly limited due to low rates of reimbursement through the MBS.
Optimal models of care cannot work in an underfunded service environment. Integrated pharmacy is another clear requirement.
Ensuring the holistic needs of patients with dementia requires much more focus and there has been good research around this.
More broadly, the emphasis needs to be placed on individualised care in supporting those with complex care needs including negotiating priorities for those with multimorbidity.
In meeting the complexities in medications, in rehabilitation and functionality combined with broader family decision-making requirements it really requires a good team.
These teams should be supported by a financial model which can allocate time for multidisciplinary case conferences.
Training and roles
Training is a big part of it to ensure care workers are better equipped to cope with the demands of providing this very complex care.
In a largely for-profit sector, to ensure patient-centred quality care, there is really no choice but to mandate staff ratios.
The other related aspect to this and it’s good to see it coming through in the discussion early is around valuing roles.
Starting with care workers or care assistants - we need to make this a career worth having to ensure we attract the right people and skill sets.
They must be properly paid and qualified for what is a role which carries with it a lot of responsibility.
Registered nurses and so integral to ensuring quality of care and also key to preventing adverse events among residents.
But RNs who work for nursing homes also tend to earn less than those working for other major employers.
In welcoming the Royal Commission, the RDAA called for better incentives to recruit more registered nurses into aged care facilities along with improving infrastructure.
Future policy must ensure registered nurses are in place to lead the team and this requirement should extend to prioritising RN coverage at night.
This structure is optimal and can then accommodate different levels of nurses and staffing and ensure quality patient care.
New models of nursing-home care
It really comes down to the value we place on our older Australians and I think there are some key lessons for us from other countries with strong policy in place.
There are also excellent models of care within Australia but we need a funding system to prioritise support of their development.
We also need to ensure we balance this discussion by highlighting the good work some nursing homes are already doing.
These are my thoughts to the key requirements to reform and I would welcome your contributions to keep this discussion going.
Dr Ayman Shenouda
There remains a deep undercurrent of racism in this country but it is not mainstream Australian opinion driving it.
The problem is that the public debate in and around migration is persistently led by a far-right minority.
And actively challenging such intolerance is vital otherwise I think these low debates will come at a high price for us all.
I really think all doctors must unite against racist attacks on IMGs. This is doing considerable damage and we need to challenge these views.
Where’s the evidence?
If you were looking for more evidence that the media is complicit in fueling racism it could be clearly seen on the front page of The Weekend Australian last weekend.
Beneath a headline that read ‘Foreign doctors blow out Medicare’ sprawled the most unbalanced, uninformed piece which firmly targets International Medical Graduates (IMGs) as exploiters of Medicare.
This article, whether deliberate or not, purely through a sole focus on IMGs infers that they alone are responsible for driving some very complex problems facing our health system.
Issues around over servicing and professional standards are not confined to IMGs and we have effective non-discriminatory processes in place through various codes, guidelines, and policies to address these.
Let’s unpack the bias
Starting with over-servicing and alleged Medicare fraud we’re told about “a rampant increase in IMG Medicare billing”.
The article, of course, fails to balance this with required comparators for Gross Billings for Australian Trained Doctors (ATDs).
There is also policy in place which addresses such issues – the Professional Services Review - and this is not confined to IMGs.
Some much-needed context around what might be driving such increases other than the inferred fraud would have helped balance it.
Issues such as long hours and caseload, acuity and complexity of patient need, and broader need for the specific population and working to align resources to need all factor strongly.
The predictable narrow migration narrative
The article then forewarns a policy shakeup which will see the number of IMGs or ‘imported GPs’ slashed in coming years and then states a budget return for policy justification.
This just adds to a growing trend which sees skilled migration used as political fodder.
Skills lists really are a decision for government and if we don’t need them then don’t get them.
I actually don’t disagree that we should place strict parameters around skilled migration policy to ensure we are targeting the skills most in need.
But if we do need them then we need to support them and that is the key issue here. More on that later!
Recent policy through the new Temporary Skill Shortage (TSS) visa now works through short and medium-term skill requirement.
This is a good policy reform which also works to limit the pathway to permanent residency.
Where’s the detail behind the analysis?
The article alludes to some analysis that claims average billing of IMGs — across Medicare, the Pharmaceutical Benefits Scheme, and referrals — has tripled in three years.
Let’s be clear here defining total cost as MBS + PBS + referrals in no way reflects a GPs actual income.
We’re then told that removing IMGs would result in a forecast saving of $415.5 million. This, of course, assumes that most if not all the services provided by the IMG equated to over-servicing.
The article claims this is based on a policy assumption that other doctors would not cover the equivalent Medicare services or subsidised drugs and only half as many referrals.
This is a very big assumption and one that is impossible to verify against such diverse need.
Now to provide a much-needed defense for IMGs.
A reality check on the doctor shortage
Statistics might show there is no doctor shortage in Australia but there certainly remains a maldistribution issue.
Maldistribution persists in rural Australia and with increasing remoteness you can expect to see both workforce shortages and a higher burden of disease.
This is despite efforts to increase supply through policy measures which see increasing numbers of Australian Trained Doctors (ATDs) and broader workforce supplementation measures through skilled migration.
Some policy insights
Benefits from increasing domestic supply will of course take time and we’ve made great progress with more students training in rural areas through the Rural Clinical Schools.
What is not seen beneath the supply stats are the policy complexities in regard to addressing population need, ensuring the right workforce mix, health infrastructure deficits, and distance and geographic location.
There are still too many one doctor towns in rural Australia in need of an urgent injection of basic medical facilities.
Keeping services viable in these contexts is the story not told. And it is for all these reasons IMGs remain an integral part of our workforce.
Rural Generalist Training
Excessive specialisation means there are not enough generalists particularly in rural Australia.
We’ve been working hard to address this through the National Rural Generalist Framework.
This is key to ensuring a supportive pathway providing rural exposure in order to prepare trainees for work in a rural and remote setting.
There is significant policy work currently being undertaken in this area led by the National Rural Health Commissioner.
We need to facilitate some key shifts which turns a structure which currently sees most of the training being undertaken in the bigger tertiary hospital in the cities.
We need to turn that on its head to provide more training in regional locations to encourage more domestic graduates to take up and retain postings in rural and remote areas.
Currently, they are seconded for six months to a rural area but it’s just not going to be enough to give them the exposure they need to entice them to return.
They spend most of their time training in cities and naturally build a life around that. We need to provide more opportunity for them to work in rural areas and experience the rewards.
It is just about facilitating the training to connect these doctors to the communities that need them the most. It’s really quite simple and we’re now on the right path to make this happen.
IMGs and their contribution
IMGs are the lifeblood of rural towns. They are the backbone of our healthcare services in rural areas. You see without them many rural communities would be without a doctor.
It is estimated that IMGs comprise approximately 40% of the medical workforce in Australia and 46% of general practitioners in rural and remote locations.
IMGs saved this country from a disaster over the past 10-15 years and this type of reporting is just unhelpful.
Let’s not forget that they are often recruited to work in some of the most difficult environments, with little support.
IMG is also a broad definition
If we are going to persist with a debate that sets IMGs up against ATDs then lets first clarify the definition. I don’t think it is well understood just how broad this term is. And it’s a term that sticks.
IMG simply means that you have been trained overseas and while we’re on that point it also means that you’ve not cost the country a cent in your training.
Many IMGs have been through the system, working in rural areas for many years and achieved Fellowship. These doctors are serving their communities delivering a very high standard of care.
Legacy of forced distribution
The legacy of a forced distribution policy – the 10-year Moratorium – is that the gains for our rural communities are only short term, as doctors seek to return to more populated areas.
The policy may only provide intermittent gains, and ultimately fail to provide a stable workforce for the rural and remote areas in need.
For it to work, it is reliant on a longer-term commitment from IMGs – a key consideration which currently lacks policy focus.
For some practical policy solutions, here’s a link to a conference paper from the 14th National Rural Health Conference last year: Keeping them there: shifting our focus toward IMG retention, beyond moratorium obligations
Now one final word on the debate we ought to be having. The discussion we need to be having is keeping doctors where we need them.
For rural and remote communities, we need to shift the focus toward IMG retention, beyond moratorium obligations.
But we also need to focus most on a policy which prioritises and secures domestic graduates for regional, rural and remote Australia.
A strong investment in the National Rural Generalist Pathway will support this outcome.
The reality is that we will also need to continue to rely on those IMGs currently working in regional, rural and remote Australia to help train our domestic workforce coming through.
IMGs are vital in securing the next generation of rural GPs and this is a really important point that just gets lost in these divisive debates.
Dr Ayman Shenouda