In the 148 recommendations of the aged care royal commission report launched this month, one thing was not made clear. Aged care services will be overrun by compliance procedures and overmedicalisation, threatening to render care increasingly impersonal.
Unsurprisingly, the sector needs more money, and a lot of it. The Grattan Institute estimates a 35 per cent increase in associated funding to meet the commission’s target of needs-based care for all. This will take us closer to countries such as Japan and those in Scandinavia.
I have been visiting aged-care facilities as a doctor for almost two decades, and it is sobering to witness the transformation of old age and infirmity.
Elders used to enjoy status and authority as guardians of tradition, knowledge and history. People used to lie about being older than they were. The dignity of old age was something to aspire to.
I had seen my grandparents in Bangladeshi villages pass senescence – deterioration as we age – as a shared, multigenerational experience; one where a degree of autonomy and agency are retained until death.
The modern experience in the Western world is increasingly a private, state-overseen decline experienced largely alone or with the aid of doctors and institutions.
Nursing homes arose in the mid-20th century for the transfer of patients from hospital to recover from medical illness. This history gives insight into their custodial and medicalised nature.
They have never been designed to give a sense of agency and purpose to their residents, especially when medical science has rendered death as a slow goodbye.
The steady decline in the clinical quality of staff is noticeable. A six-week course will allow you to be a personal care assistant dealing with residents who have high care needs. It is estimated that just over half of all aged-care residents are in some phase of dementia.
The royal commission focused on critical incidents such as abuse, but these are extremely rare. While its purpose may have been to underline the need for higher staffing ratios, this has unfairly demonised care workers.
Just as we contract convenience to foreign workers in the gig economy, caring is also outsourced to workers from the Philippines, Nepal or Zimbabwe.
Furthermore, it will now be compulsory to report critical incidents such as assault, further burdening organisations with compliance arrangements and unfairly victimising residents with dementia.
This also contributes to the necessity of medicating residents with behavioural challenges, which the royal commission identified as problematic and potentially life limiting.
But without quality staff to engage residents, it makes perfect sense that doctors will be called to offer chemical restraint.
One of the commission’s recommendations is that only specialist geriatricians or psychiatrists be allowed to prescribe medications designed for behavioural control, known as antipsychotics.
This recognises the dangers of overmedicating, but there is every chance the blowback of behavioural disturbance will fall back on untrained staff.
It is likely difficult residents will now be sent directly to emergency departments, further burdening our health system.
In her book Labours of Love, about the history of the caring industries, British journalist Madeleine Bunting writes after interviewing Danish nursing students on exchange in Britain: “They admitted they were puzzled by their UK studies, which had been dominated by bureaucratic procedures and risk management.
“The paperwork has become a way to avoid blame. Sometimes, it is the main criterion by which care work is assessed and inspected, creating a cycle of behaviour which prioritises bureaucracy over people.”
You can bet the Australian situation is comparable to the British state of affairs. Some of the royal commission’s recommendations will only make it worse.
Care is often wordless and difficult to standardise. It is traditionally women’s work, suffering in the market from feminine associations with self-sacrifice. The pandemic has shone a light globally on such care, particularly in Anglo-American economies where market dynamism is more prized.
But in a modern industrialised society it must be funded and delivered by people we don’t know. The commission recommends higher wages and training, but this demands we give the work greater prestige.
It remains to be seen if, as former Bank of England governor and current UN special envoy on climate and finance Mark Carney is preaching, we are reassessing what the market prices in contrast to what people value.
As an esteemed technocrat, Carney is no Oscar Wilde.
But at least in Australian aged care, we risk valuing bureaucracy over the personal touch.
This article originally appeared in The Australian Financial Review. Republished with permission.