Oct 21, 2020

If we have the guts to give older people a fair go, this is how we fix aged care in Australia

In the face of the harrowing findings of the Royal Commission into Aged Care Quality and Safety and the COVID-19 crisis, it’s abundantly clear the way we provide residential aged care in Australia needs to change.

Over the past couple of decades, government regulation has failed to keep pace with an increasingly privatised market of for-profit providers.

Successive parliamentary inquiries, productivity commissions and the like have offered many solutions, but few have been adopted. Each time we see a piecemeal approach with adjustments in only one part of residential aged care, rather than wholesale reform.

The greatest failing of our nation in residential aged care is we have the knowledge, skills and capability to deliver a world class system. Yet the abuse, neglect and substandard care continues, largely unabated.

COVID-19 and the royal commission have shone a light on a broken system

The deaths of residents during the COVID-19 pandemic, as tragic as they are, do not approach the magnitude of neglect and abuse that exists in residential aged care in Australia.

The most damning is the failure of successive governments to address the physical and sexual violence that occurs in residential aged care. It is perverse that they keep an annual tally — in 2018-19, 5,233 assaults were reported — but there’s been no action to deliver systemic changes.

The advent of a new serious incident reporting scheme is lipstick on a pig. There seems to be more concern about the reporting burden on providers and the regulator than the safety of residents.

Residents who aren’t subjected to blatant abuse may still receive substandard care and suffer being over-sedated, falling and fracturing a hip, or developing a large pressure injury.

The provider may receive a notice of non-compliance and little else. It’s the resident who dies prematurely or has a poorer quality of life.

To improve residential aged care in Australia, we first need to address the violation of residents’ basic human rights.

A human rights-based approach

The future of aged care demands an active human rights legal centre to uphold the rights of aged-care residents at policy formulation and in the courts.

Meanwhile, we must hold providers to higher standards. The current system of weak enforcement and inconsequential sanctions must change. Approved providers, their board members and executives should be held criminally culpable for institutional neglect and abuse, similar to what happens in workplaces.

Without substantive consequences, government ministers, their departments, the regulator and providers will not change their behaviour.

Alongside tackling the abuse and neglect, respecting residents’ rights means giving them a say, as well as increasing the accountability and transparency of government and providers.

Residents should be the focus — but they’re not heard

In the first instance, aged care must be designed from the perspective of the person it’s intended to serve — the older person. Residential aged care should be a place where older people thrive, not simply where they go to die.

But currently, residential aged care operates according to what’s convenient for government, aged-care providers, and hospitals.

We saw an example recently at the height of the COVID-19 crisis in aged care, where some residents with coronavirus were denied access to hospital care. In certain instances, these decisions were made regardless of whether remaining in the facility aligned with the resident’s wishes or their best interests.

Aged care operates around, rather than with, the resident. This approach was common in the 1950s when, for example, male general surgeons represented the views of women with breast cancer. Evidently, we’ve come a long way in health care, but not aged care, since then.

Participatory decision-making is a fundamental concept in society generally — an example would be public consultations about urban renewal projects — and in health care specifically. But it doesn’t exist in aged care.

Governments, many peak bodies and advocacy groups claim to speak for residents, but in reality very few do. We make excuses that it’s impossible to include residents because they have dementia, are not interested, or don’t understand what’s required to operate an aged-care home. But this is not necessarily the case.

Models for engaging consumers are readily available, as is guidance for supported decision-making, which enables people with cognitive disabilities to exercise their legal decision-making rights.

Participation must go beyond asking about what flavour of ice cream to serve with dessert. Residents should, for example, be able to influence the selection of staff, sit on the board of governance, and be consulted about the operations of the care home and the whole sector.

Establishing a national group comprised almost entirely of aged-care residents, with the addition of legal and administration expertise, and people who can assist with supported decision-making, would be a positive step. This group would report to federal parliament about funding, policy and practice reforms for aged care.

Residents need someone to be accountable — but they’re stateless

The tragedy of the COVID-19 pandemic laid this bare. Responsibility was offloaded to providers as if residents were property. Any higher accountability was shunted between the regulator and federal and state government. No one was in charge, leading to needless deaths.

We could address this by establishing an Aged Care Ombudsman with powers to investigate the performance of aged-care providers, and hold all levels of government, including the regulator, accountable for their actions and inactions.

A more radical approach would be to reimagine our representative democracy. Perhaps if the 213,397 residents living in aged care could directly elect two members of federal parliament, governments may become accountable.

Residents need transparency — but they’re kept in the dark

Residents and families don’t have access to information to inform decisions about choosing a care home, or to monitor the quality of care.

There’s no detailed financial disclosure about how funding received for an individual resident is allocated to them; nor information about staffing; nor comprehensive performance data about a provider, beyond how many non-compliance notices they’ve received.

Despite a huge number of stakeholders in aged care, government, providers, and peak bodies representing providers continue to resist any effort towards greater transparency.

Two recent examples include failing to pass legislation that would make the staffing levels of aged-care homes publicly available, and installing the national aged care advisory group for COVID-19 without any explanation of the process by which it was formed.

To get a clearer picture of how the government makes decisions critical to resident care and safety, we need to scrutinise the nature and extent of relationships between government, providers and peak bodies.

To this end, we should adopt a national public register of competing interests in aged care like some countries have to address the relationship between big pharma and health professionals.

To further increase transparency, and importantly to give residents and families the information to which they’re entitled, there are a few other things which are long overdue. We should implement:

  • a comprehensive suite of quality performance indicators to measure each facility’s performance (beyond the pitiful three currently in place)
  • an annual national expert review of serious incidents, with lessons learned to improve the sector
  • a national register that gathers data by facility on quality of life and health outcomes for aged-care residents (including premature death and injury).

It will take guts

A world-class system need not be expensive; substantial improvements are possible in the health and well-being of residents with modest increases in funding.

This requires structuring services that deliver health care, personal care, rehabilitation, palliative care, support social inclusion, and, importantly, respect human rights.

To achieve this, we’ll need to give residents a voice and establish greater accountability and transparency across the sector.

If we can address these issues, then it will be worthwhile taking the next steps to fix the specifics — such as the well-documented staffing issues.

But without these changes, whatever is built will simply collapse again.

Fixing aged care is not conceptually hard. It just takes guts to recognise we haven’t given aged care and older people a fair go, and we must set that right.


This story was originally publishing on The Conversation

Image triocean via iStock



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  1. Professor Ibrahim’s article is excellent but I struggle to read it simply because it is true. I remember finding my mother sitting in a communal area wearing a jacket but no other clothes underneath the jacket. I remember my mother’s room stinking of urine as she was dying and the communal tub of filthy hearing aides and my mother crying out “please don’t hurt me” as she was roughly turned in bed. Aged Care is a nightmare and the corporate chain that did this to my mother is still operating with ruthless efficiency.

  2. We need more people like Professor Ibrahim with the knowledge and experience to speak out as well as he does. He is spot on with the recommendations he has made in this article. Council Assisting (QCs) for the Aged Care Royal Commission have just released recommendations which closely line up with the Professor’s comments.
    We just need these to be adopted as soon as possible. A great deal can be done without spending a lot of money. Person Centred Care and a Dementia Care focus will go a long way to improve lives of people in residential and home care.

  3. Professor Ibrahim is worth reading, he is frequently right.

    If we look a bit deeper into the Aged Care problem we face the same problems we find at all levels of Government. A basic failure of honesty and transparency about conflicts of interest.

    A Crime and Corruption Commission at a federal level would have work to do in Aged Care.

    There is a lot of flawed strategic thinking in Australian Aged Care.

    Some of that flawed strategic thinking is from very smart, well educated and well paid people.

    Perhaps the lobbyists now have total control.

    For example;

    Why does the Australian Government provide guarantees for Refundable Accommodation Deposits held by foreign owned corporations, that have no obligation to hold their assets in Australia ?

    Why can an Aged Care Provider refuse to allow inspection staff into the building ? I do not know how often they do it, but the fact they can do it is bizarre.

  4. I reported Elder Abuse but I was not believed. I tried to find out what happened but couldn’t. The person I reported told me that other staff wouldn’t attend to the resident now because I had reported her. Eventually I had to leave my employment for mental health reasons.

  5. As a employee in Aged care, I tell you most of the reports of the abuse is unsubstituted and can not be proven. You can not do much about it as Police is not interested in investigating and in 90% cases family members do not want to make formal complaint. Police hardly attends in assault allegations as something like touching a residents arm can be viewed and reported as assault, now what would you do in this case or police? Poor staff have to go through painful HR process even when an incident such as this is witnessed and not occurred. No body wants to work in aged care due to the one sided storied being shown in media. Those who lecture aged care staff have probable never worked in aged care where staff are regularly work short, physically and verbally abused by residents, families and management does nothing or the ACQA.

    The government has allowed aged care to be understaffed and done nothing about it. Families complaint when a jumper is missing or shampoo is finished after a week but never talk or raise the real issue of staffing. To work in aged care, one only needs few weeks of training and placement and they are ready. They work in most unsafe conditions, work like robots, do 10 showers in 4 hours whilst being hit and punched and yelled at for $20/hour. How can anyone expect holistic care when they are not prepared to pay the poor carer and use them a factory workers. It is the for profit aged care providers how have used every cent of funding as profit, whilst spending the least on staffing.

    We all have know this fact for years and done nothing and now when things went wrong, it is easy to blame the weakest person which is the poor staff. Why would anyone work in such stressful environment. The quality agency and aged care commissioner is a joke. I hope government mandates the staffing profile/ratio and make provider spend 80% of revenue on care/staffing.

  6. Aged care facilities are out there to make money they just don’t care about our elderly they employ the with out any nursing skills they can not even communicate with the elderly because they don’t speak the English language properly they have no hygiene knowledge you name it and I could tell you more it’s a disgrace to be honest but Will leave to this for now

  7. Government agency should be working as cares in nursing homes for at least one month especially with dementia residents to see and feel exclusively how hard it is especially working with unskilled workers

  8. Almost two years on….and next to nothing done by the Morrison government.

    Nothing done by the associations that are supposed to support facilities and their residents.

    The ” findings” of the Royal Commission have been steadfastly ignored by the government. They have continued to underfund residential care while blindly throwing good money after bad at Home care and the NDIS system despite widespread cheating,under service and confusion.

    Why is the government not supporting wage rises, they control wages! Oh, yes…then they would have to fund same.

    Sounds like a government too scared to admit the damage they have brought upon the sector
    If they fix it they will have to acknowledge that they previously broke it.

    Come on Albanese…tell us what you would do and how you would improve the funding.


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