The elderly are the sickest and most frail in our society. Inevitably with age our various systems fail, but with prompt diagnosis and treatment function can be preserved allowing a longer active life. But these frail elderly are among the most difficult to diagnose, treat and nurse. Over the years since 1997, as the number of chronically sick elderly increased, more of them have been managed at home. As a consequence the number and proportion of residents with complex illnesses in nursing homes has steadily increased.
In spite of this, governments have pursued a policy of de-medicalising aged care suggesting that skilled nurses are not needed. Untrained aids with minimal training have progressively replaced trained nurses.
This de-medicalisation of their care has been compounded by the use of words that move the focus away from their frailty and need for medical treatment to support their lives. While this may combat ageist attitudes and stop the elderly from being mothballed, it also renders society unconscious of the real world we live in and that is not in the interests of the aged.
These changes include calling nursing homes 'residential aged care facilities' (RACF's) and ill patients, 'residents' even when they are seriously ill. Doctors and allied health care workers have progressively vacated the sector.
In the following sections I address recent changes that have been made that demedicalise aged care. The proposed hub will embrace the different health care professionals and work with them to address these issues.
Changes in the aged care system that demedicalise
In September 2013, the new Abbott government moved aged care out of the Department of Health and Ageing (DoHA) and into the Department of Social Services.
The post of Minister for Ageing was abolished and the responsibility for aged care was transferred to the Assistant Minister for Social Services so removing the association with the words "care" and "health". The aged were not going to be included in the new digital medical record system, although the government claimed this may be reconsidered later and that may be happening now.
The emphasis on "services" is in keeping with the governments focus on providing services rather than care and of further commercialising the sector by enticing large commercial interests to provide these services under the new policy of Consumer Directed Care(CDC). This is being done under the banner of 'choice'.
The use of the words "service" and "choice" when talking about aged care might create a more positive image about the capabilities of the elderly. But it also ensures that the public thinks and talks about the care of the aged in marketplace terms, rather than in the traditional community patterns of "responsibility", "empathy", vulnerability" and "care". While we want to be positive, simply changing worlds and creating a false impression is dangerous and often harmful. Escaping reality is not helpful.
There has been a consistent failure to examine or address the competency of the aged and their anxious families to "direct" care let alone make sensible choices. There are few plans to educate them or provide informed advisers who are truly independent of the providers and not focused on the bottom line.
Aged care has been a hot potato and government seem to be escaping their community and financial responsibilities for senior's health and welfare, by delegating this to the market.
Government are meeting the industry's demands by reducing regulation, cutting red tape, reducing regulatory oversight and delegating complaints handling to the provider that is complained about.
The marketing and rhetoric on "choice" and "service", the opening up of aged care to further competition by groups whose primary focus is on profits completes the already dismal picture.
The reality is that many vulnerable frail aged people are not your average consumers, and are generally not in a situation to be able to pick and choose. The current regime makes making major choices impossibly difficult given the lack of transparency in the system we currently have and the stressful situations in which decisions are made.
Update information: When Abbott’s initial policies in health care resulted in a savage backlash from the medical profession, Susan Ley was made Minister for Health. She has been far more consultative with the medical profession. Demedicalising aged care by moving it into social services would have been one of the issues that the profession would have spoken strongly about.
September 2015: When Turnbull replaced Abbott as prime minister in September 2015, Susan Ley was able to persuade him to return aged care to the health department under her supervision. In addition Hon Ken Wyatt MP has been appointed as Assistant Minister responsible for aged care. If there is now a genuine willingness to consult and if common sense is allowed to trump ideology on occasion, then aged care would benefit.
The Aged Care Community Hub and health professionals
The hub proposed by Professor Maddocks and extended to create an effective customer by this submission is intended to restore the balance in knowledge and power by ensuring full transparency and by creating an effective customer with power to protect and act for vulnerable residents in this more hostile and impersonal marketplace environment.
The hub will ensure that the choices on offer will be those that are needed, rather than those that are simply profitable. Consumer directed care and choice are pluses for care and quality of life but only when they are based on informed and knowledgeable independent advice.
The role of Doctors and Allied Health Professionals
The elderly have more illnesses, are more difficult to diagnose and require more careful treatment than the rest of us to make their lives worth living. This calls for more skilled care but doctors, physiotherapists, occupational therapists, podiatrists and other health care workers, including well-trained qualified nurses have steadily vacated the sector.
... However, the result is that today residential aged care houses the sickest and most disabled people in our society ...
... Despite this, the aged care system is administered outside the health care system. They are like ships that pass in the night but don't get close to hailing range ...
Source: Aged failings - MJA Insight, Dr L Mykyta (experienced geriatrician), 2 Jun 2014
The better the health and the more active the aged community, the better their quality of life, the less care is needed and the lower the ultimate cost. Australian Ageing Agenda has a February 2015 article A new call for allied health in aged care on its web site in which spokespersons for the Dental Association, Exercise and Sports Science Australia, Australian Physiotherapy Association, Speech Pathology Australia and the Australian Psychological Society all describe what they do for the aged and what the services they provide could do if there was greater access.
When we are nearing the end of our lives we need well-trained people to advise when treatment is no longer beneficial and it is time to help us die peacefully. Instead, we have personal care attendant's or workers (PCA's / PCW's) with only a few weeks training doing the caring. Dr Mykyta wants aged care to be part of the health care system, a system which is structured to care for sick people.
In my view, financial considerations and lack of on site facilities for clinical assessment and care are not the only or main reason for this flight of expertise. There are deeper less easily expressed reasons.
When there is cultural conflict between the dominant profit focused market on the one hand and the humanitarian motives and the ethic of service that drive professional groups on the other, then there is alienation and a loss of motivation. People find they cannot provide the care they feel they need to, and their efforts to do so are not supported or acknowledged. They go elsewhere.
For example, "Sun Healthcare" was one of the most financially successful US aged care corporations. It's chairman considered that there was excess fat in the system and at the bedside. Most care could be provided by minimally trained and paid nurse aids and he saw no need for well trained nurses. His company was welcomed into Australia. Our politicians were listening and were soon promoting his ideas. Who would have been stupid enough to stick around and work in aged care when he took control? Fortunately issues of poor care and of fraud in the USA, that were a consequence of these policies, bankrupted his company in both countries.
In my early submissions I hoped that doctors and nurses in the community would play a supportive role in helping the community monitor standards. Professor Maddock and Dr Mykyta want aged care trained medical experts back. They want them playing a central role in the nursing homes and the community. I can't fault that. Bring them in and let's work together. We need more trained nurses too.