Aged Care: How did we get here?

Prior to 1997 nursing homes were required to disclose how they had spent the money given to them by taxpayers. They complained bitterly about this claiming that it was too "onerous" and "inflexible". They claimed it limited innovation and creativity. The Aged Care Act 1997 abolished all economic accountability.

The providers could be as secretive as they liked and take as much profit as they could, provided they were able to meet a flawed and compromised oversight process. This was touted as rigorous in protecting the public, and the public were bombarded with a lexicon of "quality" words to claim that this was so.  A consequence of this is that the information needed to evaluate the economic performance and operation of the aged care system was lacking.

Input to inquiries has been dominated by submissions from providers who have the resources, the time, the motive, and more importantly the incentive to press their positions. Each has produced its own set of data.

The absence of financial data has been the hidden elephant in the room at inquiries ever since.

The managerialist term "stakeholders" with its associative meanings has become the catchphrase used in order to legitimise a reliance on self-interested opinion and obscure the futility of the process.

This reaffirms the findings of the Senate Standing Committee on Finance and Public Administration in 2009, to which DOHA made similar claims. The report states:

" Chapter 3: Nationally consistent aged care data
3.33 Whilst there are a number of bodies who conduct surveys on performance in the aged care sector, much of the research is conducted by private companies which offer their analysis for a fee. Therefore, their data may not be publicly available, and rather, has to be purchased as part of a commercial-in-confidence arrangement between the body in question and the purchaser.

... The committee is also concerned that different methodological approaches, which utilise different indicators and employ different definitions do not lend themselves easily to comparative analysis. Moreover, where such data is not publicly available, public scrutiny and discussion across the sector is all but impossible ...  "

Senate Standing Committee on Finance and Public Administration in 2009

This is not 1997. Every business keeps computerised financial records and information can be readily extracted using standard software.

There can be no excuse for not disclosing information. The industry is crying poor. If they want the community to believe them, they must give us access. Trust has broken down.

Fast forward to 2012 (14 years later)

The federal government announced in May 2011 that it would provide $55.4 billion for aged care over the next four years from 2011-12. Overall Australian Government expenditure for ageing and aged care during 2010-11 totalled $11.024 billion.

As a community, it is our responsibility to see that what is being done in nursing homes meets our requirements, and that our taxes provides the sort of care that we need. If there is not enough money then we need solid evidence to show what is needed, what is provided, and then discuss what we should do about it.

We need to be assured that aged care is not being rationed in order to provide rich pickings for entrepreneurs and uninterested shareholders, such as superannuation and other managed funds, or reports of alleged rorting of nursing home taxpayer funds (re The Global Mail article).

Why should taxpayers be subsidising companies like Macquarie Group, Citigroup, Westpac, ANZ and AMP, who have all moved into the aged-care sector over the past five years?  The steady cash flows provided to nursing home operators (even during a global financial crisis) is proving an attraction for private equity firms that need the cash to pay down borrowed debt.

We need to be in a position to decide if we want government to spend more of our money to alleviate this. To do this we need information and it is clear that we are not getting it.

Transparency:  An unfulfilled promise

Greater transparency was promised in all spheres of this government but there is little evidence of this within the aged-care sector. It is our view that both the Accreditation Agency and the Department Health and Ageing should collect and collate all information relating to the provision of aged care and ensure that it is readily accessible to all.

Of the over 8,000 visits and reports made to a little under 3,000 nursing homes by the Aged Care Standards and Accreditation Agency (Agency) and by the Department of Health and Ageing in the 2010-2011 year, only the 500 accreditation reports are publicly available.

The vast majority (476) of these accreditation visits were done 3 yearly at the request of the nursing home, at a convenient time, after the homes may have spent months preparing.

Such reports tell us that the management of the aged-care home knows what it is supposed to do but gives no information about what happens on the other 1,093 days of the cycle.

Research shows that residents will enter and exit a facility without ever taking part in an accreditation audit.  In other words, the quality of care they receive will not be assessed while they are alive to benefit from any improvement made as a result of the assessment.

It is still not possible for anyone in the public to find out the (total) number or nature of 'breaches' found by the Department of Health and Ageing (DOHA), OR the number and nature of complaints by the DOHA's Complaints Investigation Scheme (CIS), for any particular aged care facility in Australia.

They are of little value to a community, anxious about those who lack motivation to provide quality care.

The current limited system of late release and early removal of adverse reports from the Aged Care Standards and Accreditation Agency website is unsatisfactory. Consumers are entitled to disclosure of all past, as well as present, reports. Information needs to be presented in a digestible format. As already stated, frail older people are one of the most vulnerable groups in society and their protection should outweigh all other considerations.

In order to achieve protection for residents in aged care, community members must be able to see what the company or provider is capable of doing when no one is watching - not just when they have been given time to prepare for an inspection and not simply after providing a response to an adverse finding in order to stay in business.

For example:

  • How much money is spent on staffing, food or on direct care to residents?
  • What are the staffing ratios at the home? (day and night time ratios)
  • Do residents get permanent assignment of staff? (or are they subject to a revolving door of agency staff unfamiliar with their medical conditions)
  • Is the home fitted with air conditioning and heating? (eg, cooling systems are not mandatory - summer in some states can be very hot - frail and older residents are more susceptible to heat conditions)
  • Is the home fitted with a sprinkler system? (some states are mandatory while others are not)
  • What is the management and ownership type of the facility? (private for profit, not for profit, charitable or government run)
  • Who is the key person responsible at the facility? (manager or person responsible for facility's name)
  • Why are the unannounced visit reports performed by the Accreditation Agency withheld from the public?
  • Why can't families find out which homes were subject to substantiated complaints?  (and importantly, what did the providers do to fix the problem/s or complaint's?)
  • Why aren't the yearly unannounced visit reports published? (the community currently depend on largely outdated information contained in the well planned and announced 3 yearly cyclical site audits)
  • How much are the accommodation bonds and extra service charges - and why aren't these published and available transparently for all homes?
  • Are resident support groups encouraged - and run independently by family members?

"... It is still possible for a home to breach their responsibilities as an approved provider, as well as having serious complaints substantiated against the facility, whilst maintaining a perfect score with accreditation (44/44) - AND still manage to avoid any public scrutiny whatsoever ..."

Aged Care Crisis finds this particularly concerning for prospective aged care residents and families who are deciding on options for the best care.

A preliminary study comparing care home information in the United Kingdom, the United States, Ireland and Australia clearly demonstrates how little information is provided in Australia.

Profit before care?

There is absolutely no reason why staffing and skill levels in nursing homes should not be made public and be continuously available. The community could not see the Productivity Commission's (Caring for Older Australians) report as credible if it did not recommend this. Publishing a recommended range of staffing levels based on the sort of services provided is sensible.

Without valid data, it is impossible to make an informed decision about the real cost of aged care and how it should be funded in the future.

The primary focus of market-listed entities is profitability. This is the reason that they enter the aged-care sector.  Private equity groups now own a majority of private-for-profit nursing homes in Australia. These groups are aggressively focused on short-term profitability. They are motivated to squeeze the system for profits so that they can sell and leave the sector.

Within this setting, managers distant from the coalface, make top-down financial decisions with little understanding of the consequences for the residents for whom they are ultimately responsible.

Caring for old, frail and vulnerable people is labour intensive. It requires an adequate labour force consisting of individuals who are well trained and devoted to the task. Sadly, it is often those staff who seek to provide humanitarian and personal empathic care who leave the sector in frustration with their inability to provide that care when the prevailing culture of the home relates to cutting costs.

It is as simple as ABC to know that caring for both the very young and the very old is a community responsibility and should not be driven by the need to generate profits.

Looking for.... staff

Many people who contact ACC are shocked to learn that there are no mandated staff/resident ratios (or mandated skills) for aged care workers in aged-care homes across Australia. We have mandated staffing levels in childcare centres, kindergartens, schools and hospitals - they, too, cater for people with different levels of needs in different locations.  Why are vulnerable, frail, older people discriminated against and missing out on this protection?

Aged Care Crisis strongly recommended in our submission to the Productivity Commission's Inquiry Caring for Older Australians that a substantial review of the current meagre staffing requirements which generally, and in our experience in seeing complaints and comments from people directly involved over the years, falls far short of the Aged Care Act 1997.

In fact, only one sentence out of the Aged Care Act's 1997's 500 page document are allocated to the most vital aspect of care provision:

"to maintain an adequate number of appropriately skilled staff to ensure that the care needs of care recipients are met".

Part 4.1 - Quality of care - Paragraph 54-1 (1) (b)

What residents need

Residents and their family members care about whether they are being well fed and sufficiently hydrated (assisted with meals if needed), assisted with their dental hygiene;  help with their medication;  assist mobile residents with walking; help with hearing aids or other equipment;  assisted with going to the toilet and not forced to lay in pads soaked with their own urine and faeces for long periods;  to be turned regularly so as to avoid painful bedsores; and not to be inappropriately restrained physically or chemically with restraints.

It is also extremely important for the quality of residents' lives that staff has the time to talk to residents, even when they cannot respond. This is their home and often staff contact is is the only regular human contact they receive.

Many of these issues get back to the fact that many places do not have enough skilled staff on duty.

'Caring for older Australians': an opportunity lost

The Productivity Commission's Inquiry "Caring for Older Australians" Commissioners have largely neglected the critical issues of aged-care staffing which are fundamental to the provision of high level care. The inquiry did not advise the compulsory disclosure of care acuity or staffing structures in aged-care homes.

In the absence of compulsory staffing ratios, this is the most critical information that any family will need in making a care choice.

Aged Care Crisis is concerned that this report reflects the interests of aged-care providers and does not give due emphasis to the concerns expressed by family members and aged-care staff as expressed in their many submissions to the Commission.

Related: Media release - Caring for older Australians: an opportunity lost


More information:

For a detailed history of how aged care evolved in Australia over the years, we strongly recommend you read Dr J.M. Wynne's web pages which page examines some of the many inquiries and reviews relevant to the aged care sector conducted during the 14 years between 1997 and 2010. That there is still widespread concern about the operation of the sector is clear. In 2010 the Productivity Commission's Inquiry Caring for Older Australians was asked to come up with a blueprint for reform.

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