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A/Prof Ayman Shenouda

01 Oct 2018
Column

Do we need a royal commission into aged care to tell us what the sector needs?

Ayman Shenouda

1/10/2018 12:05:49 PM

Dr Ayman Shenouda examines what has been learnt from previous inquiries, the commission’s priorities, training and roles, and new models of care.

Dr Ayman Shenouda believes ensuring a key role for general practice is an integral factor in improving aged care service provision.
Dr Ayman Shenouda believes ensuring a key role for general practice is an integral factor in improving aged care service provision.

There is hope that ensuring dignified support for people in aged care will be one step closer with the recent announcement of a royal commission into aged care.
 
I certainly welcome the news and see it as a key step towards ensuring our patients get the care, support and dignity they deserve.
 
This not only provides hope for patients and their families, but also for those who are working in the sector and committed to providing consistent, quality care to their residents.
 
What have we learnt?
Most working in the aged care 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.
 
This 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 inquiries into aged care by the Senate and others since 2009. Federal Aged Care Minister Ken Wyatt admitted as much only a few weeks before this latest policy shift.
 
‘After two years and maybe $200 million being spent on it [a possible royal commission into aged care], 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,’ he said before the Government’s recent announcement.
 
Let’s not forget the states, who have also had a strong focus over many years. There is plenty of positive state-driven change.
 
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 for 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.
 
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 residential aged care that can support GP decisions. It’s a step-up approach to support interventions to reduce acute hospitalisations from residential aged care facilities (RACFs).
 
Reducing unplanned admissions means we have to start dealing with those issues in the RACF setting, and 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 Medicare Benefits Schedule (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 are met requires much more focus.
 
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, 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 that can allocate time for multidisciplinary case conferences.
 
Training and roles
Training is a big part of ensuring workers are better equipped to cope with the demands of providing what is very complex care.
 
In a largely for-profit sector, there is really no choice but to mandate staff ratios in order to ensure patient-centred quality care.
 
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 in order to ensure we attract the right people and skill sets. They must be properly paid and qualified for a role that carries with it a lot of responsibility.
 
Registered nurses (RNs) are so integral to ensuring quality of care and also key to preventing adverse events among residents. But RNs who work for RACFs also tend to earn less than those working for other major employers.
 
In welcoming the royal commission, the Rural Doctors Association of Australia (RDAA) called for better incentives to recruit more RNs into aged care facilities, along with improving infrastructure.
 
Future policy must ensure RNs are in place to lead the team, a requirement that should extend to prioritising 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 care
It really comes down to the value we place on our older Australians. 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 RACFs are already doing.
 
A version of this column was originally published on Dr Shenouda’s blog.

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Adam   2/10/2018 6:20:57 AM

I would suggest that lobbying focus on increasing existing rebates and the addition of incentives to provide GP care to RACF's. Wholesale model change that moves away from fee for service is likely to erode conditions for GP's at least in the longer term. Moves to any sort of capitation payment and KPI system will be used to expect more service for less over time. Fee for service is remarkably efficient and creates a huge work incentive

Max Kamien   2/10/2018 7:50:47 AM

I doctored in the dementia wing and sat on the Board of one of the 'criterion' aged care homes. It had excellent community, family and volunteer connections.
Although a not for profit organisation finances were a constant problem. Form filling bureaucracy resulted in a gradual increase in clerical staff and a diminution in the number and the quality of carer staff members. One 'positive' spin' was that over a period of 5 years we employed people from 122 different countries. After 4 years I had made no inroads into improving residents' care especially in the types and zombie making medications that were requested and given to residents. I fully agree with Dr Shenouda that another Inquiry is a waste of time. The solutions are obvious. If only residents with dementia voted. On second thoughts, maybe they do.

Mary-Anne Lee   2/10/2018 9:44:07 AM

We need multiculturally based aged care for the elderly since we have become a multicultural society.Particularly those with any degree of dementia often hang on to their long term memory and from that stems the craving of food tastes from their childhood.
My own father passed away this year at 92 yrs having spent the last 9 yrs in care.Despite being in Australia from his mid teens, the last 5 yrs were spent ensuring daily that he had Chinese dishes with chives, garlic,soy sauce ,dumplings etc
The rules would not allow staff to reheat the food I brought in due to a food poisoning risk and yet I could come in to reheat the same food for Dad. ????
He loved a lightly fried egg folded in a slice of bread but all yolk had to be well cooked due to food poisoning rules ????? They would rather throw out the uneaten firm rubbery eggs than to make proper poached eggs that residents would enjoy.
Somehow the aged are considered as people who don’t need to have one of the basic sources of life’s enjoyment that being tasty food.

I have so many more issues from my journey within nursing homes with my late Dad.

Dr Ian Light   2/10/2018 10:31:45 AM

GPS need forensic training to monitor aged care standards with powers to report anonymously to authorities effective in fixing brocked and malevolent systems .

Dr T   2/10/2018 10:53:07 AM

Unfortunately the GPs who visited my mother in her low care facilities were part of the problem. I suspect that aged care managers prefer GPs who take a very backseat role to patient care and do not cause much trouble for facility managers. WHen I questioned one GP about why he had started my mother on a Fentanyl patch for back pain instead of say, trying non pharmacological methods such as exercise and trying non-opoid medication first (maybe even looking at possibility of depression), his response was "So you want your mother to be in pain do you?".

Chris D Hogan   2/10/2018 11:03:40 PM

I sympathise with those who say that we have talked enough- let us do something. Enough of paralysis by analysis for I am also sick of things just slowly getting worse.
I have a multicultural background, but each of those cultures values the aged, their wisdom, their care & the love they have given over the years. Does our present society care for our aged? Or do we just wish to provide them with rapid access to voluntary assisted suicide?
As Ayman says we need to value not only the aged but those who care for them.
*We need to support the families, providing education about the conditions affecting their loved ones
*We have access to case conferences but they are not affordable
* I have found that miscommunication is much more common that maltreatment. Staff need assistance to deal with bizarre & inappropriate complaints. A complaints system that is established to solve problems rather than a judicial designed to apportion blame is a start.
* All medical, allied health & other staff need to be provided with wages & conditions equal to all other medical sectors
* All aged care facilities need to be assisted to computerise their records. The improvements this allows in legibility, decision support, communication & risk reduction is immense. Records can also be adapted to assist people with decreased literacy & numeracy. This is much more common in aged care than would be expected but is rarely looked for. Having a system compatible with GP systems would really help.
* Why are “scripts owing “ still such a major issue?

Debbie L Gawley   4/10/2018 8:15:30 PM

My Mother was in Bolton Clark age care Cairns her care in the 6 years was not adiquit. She often suffered in silence. Never like to complain. The food was not fit for anyone. several complaints wer made but nothing done. I bought food in for mother yet she paid to be there. My mother was injured by staff on several occasions. She was left in an aid for long periods of time. One staff was cruel and nasty towards her. My mother was a caring person never wanted anyone to get into trouble. The system neds to change more money for staff and training for high care.

Brenda Munro   22/10/2018 1:51:50 PM

My mother recently passed away, she was 100, I had promised her that she was never going into care. I had SJOG nurses three times per week showering her and carrying out vital signs, a cook who cooked her meals just the way she liked them, pediatrist, library lady, gardener, a local doctor, morning and evening carer's helped with bed, blinds and food also a house cleaner all these employed by the local council. My mother socialized with all these people. Every week she would go to a day center and do ceramics, again socializing, every day she would do a crossword and play her Nintendo DSI, and loved watching sport. I rang her every day to make sure all was going well as I live interstate, Well done mum, I miss you.

Anonymous   26/10/2018 7:31:29 AM

Have worked in aged care for years slowly watching the standards of care disintegrate . Big companies like REGIS and BOLTON CLARKE consume smaller providers . Their sole purpose is to make MONEY some even go under the banner of NOT FOR PROFIT nothing could be further from the truth .They cut staffing levels to a impossible ratio 3 to 30 residents for the first hour of a day shift try assisting 10 people onto a toilet and or into a shower NOT POSSIBLE . Oh but another staff member starts at 7 gee can you just wait a hour till backup arrives LOL . Yep so the 4 to 30 residents for day ,3 to 30 for afternoon and 1 to 30 for nights ,that is if every one turns up to work SICK REPORT through the roof .When families complain its staffs fault, when residents complain its staffs fault ,and if you complain YOU GET BULLIED and THREATENED by management . I say SHAME,SHAME on the government you knew this was happening .SHAME, SHAME on the companies for financially abusing old people .

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