Resourcing, not medication restrictions, needed in aged care

Michael Clements

9/12/2019 3:14:11 PM

The Government’s recent funding injection has to be specifically targeted to address the problems GPs, staff and patients face within residential aged care facilities, Dr Michael Clements writes.

Aged care
Dr Michael Clements believes that while aged care requires a significant funding boost, it will only be helpful if it is specifically targeted to the sector’s needs.

‘Mrs X was found wandering at night in the carpark, can you please prescribe medication?’
This was how one recent residential aged care facility (RACF) interaction began for me.
After meeting with the staff and ruling out delirium or biochemical causes, and noting a worsening in the behavioural aspects of dementia, I suggested the patient move to the restricted ward or have extra supervision.
But my request was declined due to lack of beds and I was specifically asked, once again, to commence a medication to prevent the patient from wandering.
The situation was clear: under-staffing in this facility led to pressure to prescribe sedative medications that would keep the patient compliant and allow staff to attend to other residents.
Provision of care within RACFs has become more complex and time-consuming as the population ages and rates of dementia rise. Unfortunately, funding models have not kept pace, even as clinical governance requirements in RACFs have increased and nurse autonomy reduced.
This has led to a situation for many GPs who work within RACFs in which countless night-time phone calls, form-signing, box-ticking and compliance measures now form the largest part of their care. It has also led to an overreliance on anti-psychotic medications for the behavioural aspects of dementia, as understaffed facilities come under pressure to medicate their problems away.
GPs have been looking forward to the Royal Commission into Aged Care, Quality and Safety because they, along with RACF staff, have seen cost-cutting measures applied in facilities, with reductions in numbers of trained staff, greater reliance on lower-skilled assistants, and decreased activities and programs.
Staff across the aged care sector want to see better diversionary activities and care services, nursing numbers, and funding to allow GPs to spend more time with patients and their families. This is felt most acutely in rural and regional areas, which are already experiencing aged care staff and GP workforce shortages.
The Federal Government has suggested high prescriptions of anti-psychotic medications in RACFs is a source of the problem, rather than an indicator of a system that is under-resourced to deal with the complex issues of dementia care.
However, the latest promise of extra funding from the Federal Government does nothing to address the reasons behind the increased use of anti-psychotic medications for the behavioural aspects of dementia; it is simply ‘shooting the canary’ and will have no impact on the gas leak in the coalmine the canary has been screaming about for the last five years.
What RACFs need instead is funding targeted towards sufficient numbers of appropriately trained nursing staff, for GPs to provide comprehensive team-based care, and for tertiary services to get out of hospital grounds and into RACFs to work with GPs.
Novel solutions are required to the problems faced in residential aged care, and each facility will need to find one that reflects their community workforce and need.
But some general steps that will be helpful across the board include:

  • additional money injected into the system from federal and state health budgets
  • patients getting used to private fees for GP services
  • nurses and nurse practitioners being allowed to practice at their full scope
  • GP-led rather than GP-delivered care being utilised where possible.
The message should be clear: fund RACFs and GPs in order to enable them to provide the care that is so desperately needed.
Do not shoot the canary.

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Dr Christopher David Mitchell   10/12/2019 8:02:59 AM

Michael has nailed the issue here and with a great example
Working in Aged Care Facilities gets harder each year
This is a critical issue for the RACGP and its members
I'm meeting with my local Federal member of Parliament to discuss my concerns and Ill take this article with me
Thanks, Michael

Dr Alison Fiona Sands   10/12/2019 10:42:46 AM

Thank you Michael for capturing the issues so effectively and succinctly. I worked for 10 years caring for 30 residents across two RACFs before I gave up. My experience 100% reflects everything you have written. If those issues were addressed I would be happy to go back to working in RACFS, but I fear I’ll be too old before those changes take place (I may be in one of those beds by then!).

Dr Annette   10/12/2019 2:08:00 PM

Can't agree more. Been saying it myself for years. We need more people (carers, nursing staff), not more drugs - but as there are no more people (and getting less every time I look), we will end up using more drugs. How about using some of the many staff who spend all day on accreditation paperwork and juggling figures to get more money from ACFI? Blaming GP's for excessive drug use is an easy way out of taking responsibility for larger failures within the system.

Dr Igor Andre Jakubowicz   10/12/2019 9:02:10 PM

Great article. Left out some of the other call-outs - review consumer who "fell" from low-low bed onto a crash-mat - consider night sedation so they'll sleep better. Automatic transfers to hospital for "falls" if on anticoagulants take up lots of resources - and the hospital doctors may stop the anticoagulant leading to 50% risk of stroke where the risk of intracerebral bleed is 1:296 falls.