The Oakden Review report2.74 MB is like Groundhog Day to Aged Care Crisis. What is shows is that we will not have a safe aged care system where the elderly can lead fulfilling lives until we have changes that include:
- safe levels of staff with the required skills,
- local community involved in the management of aged care services, and
- locally based independent regular oversight directly accountable to the local community.
Aged care has traditionally been a community responsibility – part of a caring society. While we may no longer provide all of that care ourselves, we are still responsible for one another. Those who provide that care on our behalf should be directly and transparently responsible to us.
Staffing a key problem in aged care
Our supplementary submission to the Aged Care Workforce Inquiry found that staffing levels in Australia are so far behind international standards, that there must be many homes that have similar problems to Oakden.
Information about staffing levels has been hidden from us for years, so deliberately keeping the community in the dark, and in doing so, denying us the opportunity to fulfil our responsibility to protect our senior members.
Accreditation - a flawed regulator
Oakden glaringly exposed how flawed our accreditation system is and how unsuited accreditation is as a regulatory process. It has been heavily criticised for years and the government is now planning to bring in a new truncated accreditation process for all aged care services under the guise of the Single Aged Care Quality Framework. Aged Care Crisis (ACC) does not see it as an improvement.
The systemic problems in the current accreditation system are not addressed by the proposed new framework. Both are based on the flawed logic of the Aged Care Roadmap, which assumes these 'consumers' can 'pick and choose'. ACC has made a submission1.38 MB challenging this.
This framework is based on the misconception that most, if not all aged care patients are capable of being effective customers or 'consumers', who make informed 'choices', take 'control' of their lives and hold the market to account. They often must do so at times of great stress.
This has not and will not work for frail patients in aged care.
It did not work for those at Oakden.
The Aged Care Quality Agency charged with accreditation of nursing homes across Australia is staffed by the industry and run for the industry rather than for community members. They believe in the Aged Care Roadmap. It's as if their primary purpose is to protect industry and government from embarrassment rather than identify and address failures in care.
For this reason, family members across Australia with a loved one in care can take no comfort whatsoever in the fact that nearly 100% of aged care homes across Australia are accredited by the Aged Care Quality Agency.
What happened at Oakden over the years illustrates this, but there have been many other examples.
Aged care homes like Oakden have weeks to prepare for the infrequent accreditation visits and they put on a good show which is not representative of what happens at other times. Regulators too willingly accept this as representative and when they do find problems they readily accept assurances that these have been corrected.
The various state and federal oversight and regulatory bodies do not work effectively together. They are ineffective in countering the pressures towards dysfunction created by competition that in the absence of an effective customer and an alert community is all about profitability.
The regulators are too far away and visit too frequently to be effective. They do not think like the community and do not work with them so do not operate in their best interests.
Finger pointing and blaming individuals for an oversight system that is not fit for purpose is counter-productive. Simply calling for the same system to be more rigorous will not address the underlying problems.
Oakden illustrates the central problem in the government's competitive aged care market and in its centrally controlled regulation. Most frail patients in aged care like those at Oakden, are not sufficiently informed, empowered or able to make choices to protect themselves. Their interests can and have been ignored.
As a community we have a responsibility to fix this because government has not. Until the patterns of thinking that determine policy are changed it will not.
The lessons from Oakden should not be forgotten. We must learn from them.
A better system
Aged Care Crisis argues that much of the management and oversight of aged care could be done through empowered local organisations in regular contact with nursing homes, residents and staff.
Any problems identified could be addressed immediately and not be dependent on the chance that an occasional visit from a state or federal assessment, audit or regulatory body might identify them.
Communities could form local groups of interested people and volunteers, with some experience and put strong pressure on government to work with them and give them control over what happens in their communities. They are in a position to monitor what is happening to residents and staff.
We have made some preliminary suggestions as to how this could be done in our proposals for a Community Aged Care Hub.
A flawed accreditation system is getting worse
Oakden exposes a deeply flawed accreditation system. But that system is in the process of being changed. Aged Care Crisis is very concerned about what is being proposed in the Single Aged Care Quality Framework.
Our assessment is that if our current system is bad, what is proposed is going to be worse. It does not address the problems in the current system and it is going to become even more difficult to identify and expose the flaws in accreditation because, although they sound very appealing, the new standards will be even more difficult to evaluate within the sort of system we have.
Aged Care Crisis have made a submission1.38 MB criticising the changes and it used Oakden to illustrate the problem. Many of the criticisms apply equally to the system that is being replaced. The following section is an extract.
Analysis of the proposed Single Aged Care Quality framework
During 2016 the government through the Quality Agency ran a consultation process under the 'Quality' brand. This was more about popularising the Aged Care Roadmap by creating images about the choice, control and flexibility that the roadmap claimed a free market system would provide. The discourse was clearly set out in preliminary documents.
What eventuated was a system of 8 standards instead of 44 and the new ones included the aspirational ones that had been developed at the previous session. In themselves, these are desirable but assessing them will be very difficult under the present system and it is what it hides that matters.
It does not address the problems in the current system that resulted in the Oakden debacle and instead reduces the actual measures of care.
The industry has been clamoring for less regulation and more freedom 'to be innovative' for years and the proposed changes will give them that.
The proposed 8 new standards are about:
- dignity, autonomy and choice,
- assessment and planning with consumers,
- delivering personal care and/or clinical care,
- lifestyle services and supports,
- service environment,
- feedback and complaints, human resources, and
- organisational governance.
While there is nothing wrong with any of these objectives and they all feel good, many can only be assessed subjectively and doing that through occasional infrequent visits is going to be unreliable.
If we are to have effective customers then not only do they need to have mental and physical capacity, but they need accurate objective and independent data. The new framework is going to give them even less than they had before.
In keeping with the Aged Care Roadmap the focus of the standards is on what 'consumers' want rather than what they need. They want consumers to want choices because this will enable providers to offer them choices that they will pay for – choices that could be marketed to the vulnerable and which they may well not need or really want.
Aged Care Crisis have made a submission1.38 MB criticising these proposed changes and suggesting a local oversight process organised within communities. The following comments are taken from that part of the submission.
General comments about what consumers say they want
The consumer outcomes in the proposed draft standards in the Single Aged Care Quality Framework ignore the essential requirements that are needed to make these attainable. They reflect a very limited form of populist 'market-speak'.
They do not adequately recognise the vulnerability of the elderly and their families or the important role of the community in relationship to markets and politics within capitalist democracies.
The basic assumptions underlying current aged care policy and the proposed Single Aged Care Quality Framework are questionable because their value is overstated and because necessary pre-conditions are not being met.
Essential pre-conditions for aged care:
- Maintaining the health and wellbeing of the elderly by ensuring the basic staffing and other resources needed. There are clear international guidelines that are being ignored and there are no plans to meet them.
'Sufficient' is not a standard. Standards should reflect acuity and available research and not support or shield mediocrity as currently occurs. It is clear that the standards are not, as claimed, based on demonstratively effective international standards or regulation.
While the USA, which collects data and makes it publicly available, does not meet these standards, our residents receive less than half as much care from trained nurses, and over an hour’s less nursing care of any kind per day than in the USA.
We have a sector where there is no information about staffing or the frequency with which sub-optimal care is given. This is the information families' need when making informed choices.
- Research indicates that the next most important factor in successful care is the relationships between the elderly and those who care for them. Trust and trustworthiness must be central.
- An equally important consideration is control because the elderly person’s mental stability and their quality of life depend on their ability to manage their environment and what they do there – to feel on top.
- A stable environment is important if the elderly are to maintain control, mental stability and a sense of self. Shopping around might sound attractive and conceptually appealing, but in practice the disruption and angst created makes it an unrealistic option for the elderly. It is a last resort.
- The final omitted important consideration for the vulnerable person is support because this both empowers the person and mediates inappropriate or antisocial behaviour. It protects them from themselves and others.
These necessary pre-conditions are not considered or adequately catered for in the currently structured competitive market system and in these standards.
These are essential for the effective implementation of a policy that includes the availability of choice and flexibility in this sort of marketplace. The preservation of dignity and identity are also dependent on trusting relationships, control and the support of people we can trust.
Support and community
Because of the pressures introduced by competition for profit over service, successful markets depend on a measure of distrust and customer empowerment. In this sort of market, self-interest and self-preservation undermine altruism and civic responsibility.
In the 1993 report to government on which the 1997 reforms were based, Gregory indicated the difficulties in regulating a free market in aged care. He noted that “neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit”. That problem remains and the proposed Single Aged Care Quality Framework does not address it.
To counter this:
- An effective, empowered and supported customer receiving advice based on first-hand local knowledge of the services provided, is essential for a competitive market built around choice in this sector.
Current aged care policy and these standards fail to address the inherent vulnerability of the elderly and their families. They ignore our human inability to handle complexity during times of stress. The trusted support of knowledgeable people they know and trust is needed to empower them.
In spite of the extensive availability of data in the USA and a 20-year focus on encouraging choice, major problems persist. The poorest performers in staffing and in care remain the most profitable and the most successful in the competitive marketplace. This is because the focus is on the consumers rather than the community support needed to be effective. US citizens are not getting the local support needed to use this data effectively.
- Such a market also requires oversight by an effective civil society (community) that is involved with and supportive of its members when they are in need. Such a society has the power as well as the close regular contact needed to exert it. Patterns of relationships between the providers of care and the local communities are needed to ensure the adoption of community values and norms by the marketplace. This would ensure that the market operates within their expectations and altruism is not undermined by self-interest.
Missing from the Single Aged Care Quality Framework documentation and the standards is any reference to, or place for, the community that in a civil society is ultimately responsible for the wellbeing and care of its vulnerable members.
We have a society that has of necessity delegated aged care services to government and the marketplace. That should not absolve it from its responsibility for ensuring that both meet its norms and values. Both have regularly failed to do so.
Frail patients are not your regular 'consumers': The current proposals seek to marginalise the community and so escape these constraints. The term 'consumers' does not adequately embrace 'community'. The documentation talks of support, but how this will be provided is not indicated. If this is to be delegated to the market, then it will not effectively counter self-interest.
In a section about the relevance of the standards:
Accreditation as Regulation: These new proposals expose the flaw in attempting to use accreditation as a regulatory mechanism in vulnerable sectors. Control of the predatory nature of markets depends primarily on social control in the community and effective regulation is required both to enable this, to support it and to step in when it fails. Regulation is not a substitute for direct social control in the community. Accreditation is a supportive activity and not a regulatory process. No other country uses it in this way.
The (then) Accreditation Agency recognised this itself in 2010. In its submission to the Productivity Commission it asked unsuccessfully to be relieved of its regulatory role. Government’s response to this different and unwelcome perspective within the Agency was to put accreditation directly under government control and put a leading figure from the industry in charge of the process.
This has done nothing to increase confidence in the process. Reducing the number of standards from 44 to 8 using the same accreditation system further undermines confidence in its effectiveness.
Giving comfort to poor services: There is no more graphic illustration of the harm caused by confusing accreditation with regulation than the state operated Oakden nursing home in South Australia. An independent review by the state’s Chief Psychiatrist has revealed how between 2005 and 2017 the accreditation process was used by the state to justify the continued operation of the facility in the face of clear warnings and multiple red flags.
The service was “up to 44 staff members short” and for years “has had insufficient access to Social Work, Occupational Therapy, Psychology and Clinical Pharmacy services that would be critical for ensuring the service provided a high level of safe care”. Residents in this dementia unit had been abused for many years.
The Adelaide's InDaily describes how unreliable “periodic reviews" are and the way in which accreditation “gave comfort” to the state’s managers.
Community groups like Aged Care Crisis and others have been writing about this for almost as many years.