Professor Joseph Ibrahim gave an impassioned hearing at the royal commission on Thursday, delivering a damning assessment of Australia’s aged care system, and laying down his suggestions, based on decades of research, for improvements.
Prof Ibrahim is a consultant specialist in geriatric medicine, who teaches and researches patient safety and aged care at the Institute of Forensic Medicine and is head of the Health Law and Ageing Research Unit at Monash University.
Prof Ibrahim investigated the causes of death in nursing homes reported to the coroner between 2000 and 2014, and found 22,000 deaths had occurred in residential nursing home from a total 230,000 deaths.
Of these, 3,289 were from injury and 18,000 were natural cause deaths.
Prof Ibrahim questioned why these deaths were reported to the coroner.
“As most people would know, deaths reported to the Coroner usually have some unusual aspect to them, and we remain curious to this day as to why 18,000 natural cause deaths have been reported,” he told the royal commission.
Only 39 deaths reported to the coroner were the result of complications of clinical care, which “beggars belief”, he said.
Professor Ibrahim said it was costly and difficult to get data for his studies from the Department of Health and the AIHW.
“Linkage of data”, for example between hospitals and ACFI, would be “incredibly helpful”, he said.
Prof Ibrahim said there is no agreement on what aged care is.
“You can’t measure something if you can’t define it, and the beauty for the Parliament and for the Government and for the Health Department is if it’s not defined, you can’t ever do anything wrong because you can switch your definition or what you think the role is. And you will have seen from residential aged care is on one hand it’s a palliative care unit when you want it to be, and then the next minute it’s a brokerage or concierge service for people to go skydiving.
“The product of residential aged care is death, and deaths occur one third every year and so it seems that residential aged care is working well because every year 35 50,000 people die and that’s what we expect so things are happening smoothly,” he said.
Aged care should be a place that people can enjoy, he said.
“I believe that residential aged care is a place where older people should be able to go and enjoy their life.”
“I would have thought at that point in life you deserve to have something decent happen to you, and so I think that residential aged care should have the goal that it’s a place where people can at least enjoy their last few months or years before they die,” he said.
Mr Peter Bolster, read a transcript to Prof Ibrahim about the fact that residential aged care facilities are not a ‘home’, they are an institution.
Prof Ibrahim said there are different populations in aged care and each has different requirements.
“There are at least three populations that access residential care at the moment: those that enter and die quickly within a month to six months; those that are there for more than three years and some more than six years; and then there’s a middle group. The needs of the residents are different and so some residents need a home-like atmosphere with – activities is the wrong word, but they need somewhere to live because they need help with their personal care and they need to be able to have a purpose to their lives.
“Other people are frail, needing palliation and palliative care with high-end nursing care and pain management. And then there’s a large group of people who have multiple chronic diseases that need fine-tuning, regular clinical assessment to make sure that they’re in optimal health to enjoy their life.”
“We haven’t actually asked older people what they want and if we have asked them, we haven’t listened,” he said.
Prof Ibrahim said the purpose of building nursing homes often appears to be profit.
“We’re designing things based on… square footage because the square footage of your room determines your ingoing fee and what you can charge people. So if I’m being charged extra for a window and double for two windows, then the decision about the build is not from the residents’ point of view; the drive for the build is really for profit,” he said.
Prof Ibrahim said aged car facilities are promoted as a place where residents will be ‘safe’, but he said that sometimes isn’t necessarily true.
“If you think that’s safe, well, that’s safe, but that does not mean no harm will befall you,” he told the royal commission.
Prof Ibrahim said suicide was a topic that is not being adequately addressed in aged care, and that needs to change.
“Residential aged care was not considered an at risk population [for suicide], so there were no interventions there,” he said.
New assessments will help, he said, but more work on “prevention” needs to be done.
Prof Ibrahim said the government reports on sexual abuse in aged care, but does not make use of the data.
“All I know is what is in the annual reporting requirements the Department has to do according to legislation, and they provide a one paragraph summary saying the number of incidents that have occurred. There’s no state breakdown. There’s no breakdown of nature. There’s no breakdown, whether it’s resident or staff perpetrated. There’s no explanation as to whether they’ve used that data or fed it back…
“I would happily analyse that data for free if it was provided to our team,” he said.
The reporting exclusion for people with cognitive impairment “makes no sense,” Prof Ibrahim said.
“The exclusion for people with dementia makes no sense because the people with dementia are the ones at the greatest risk, and so we set up a system which is not accountable to anyone,” he said.
Prof Ibrahim said the use of physical restraint in aged care is “disrespectful and really ought not be allowed”.
“The only possible justification is if there’s an imminent threat to life that you might restrain someone.”
“It beggars belief that it still goes on in aged care,” he said.
Prof Ibrahim said his finding that respite care can be a dangerous option for people “caught us by surprise”.
“Respite care is for the carer, not for the person who is in respite,” he said, noting that it is “really important” to have strategies to help carers because over 50 per cent of carers have physical or mental health issues related to the “burden of caring”.
“But if I take a person from their home, from their loved one who knows them intimately, knows their habits, their likes and dislikes, they know the layout of the house, they know where the step is, they know where the lights are, they know where the toilet is, they know when to take their medicines, and I take them to a strange new place where there is noise and people I don’t know who say things in ways I don’t know, with a layout I don’t understand, with no indication where the toilet is, who aren’t giving me my medicines on time or the way that I normally like it, it should be no surprise that I will slip or fall or become incontinent or become distressed or want to leave,” Prof Ibrahim said.
Prof Ibrahim said similar risks apply in all healthcare, but the risks there are managed, whereas the risks are not managed in respite care.
Prof Ibrahim said he supports an “open door policy” in aged care.
“It just makes no sense not to have a policy that allows people freedom of movement,” he said.
Prof Ibrahim said the residents of Australia’s aged care system are “stateless”.
“Parliament does not care about people in residential aged care. If they truly care, they would do something,” he said.
Prof Ibrahim said nurses are the best clinical specialty to work in residential aged care, rather than doctors, but that more cross-training with allied health services – such as speech pathologists, physiotherapist, and occupational therapist – can “make a difference to a person’s life.
“If it wasn’t for the nurses in the aged care system and the people there now, the whole thing would just be a complete catastrophe,” Prof Ibrahim said.
Image: Aged Care Royal Commission.