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