What is the real problem behind the failures in aged care in Australia?

While there is an enormous effort from many parties to point the finger at others there are three major factors that have contributed to the demise of aged care in this country – A failure of funding, a failure of delivery and a failure of regulation. This position is based upon nearly 30 years in the sector, working for providers, working for government as a Compliance Officer and Clinical Advisor and as the guardian of a resident living in an aged care home.

A Failure of Funding

While it can easily be argued that we really don’t know whether there is enough funding or not because of the woeful lack of transparency surrounding billions of dollars of taxpayer funds, based on almost 30 years on both sides of the aged care fence, I have to conclude that if you actually want to deliver the highest quality of care to older Australians, with optimal staffing and in a truly resident centric way there simply is not enough. 

There isn’t enough to start off with and then far too much of the total aged care budget is often squandered by ineffective government agencies, administration fees to support bloated providers, money supporting providers churches, clubs other non-funded entities and a funding system that is more reminiscent of a cat and mouse game than a legislated health funding process.

The notion that a provider has to expend huge volumes of resource to undertake assessments and complete documentation completely outside a clinical process only to administratively satisfy the substantiation of claims and then the government spends millions in return validating this process is an absolute nonsense. While the ACFI may provide a blunt instrument to determine the cost of care, it fails to take into account WHS obligations, staff competence, staff numbers, building design, operational processes and most importantly, the individuality of residents. This is not news to anyone vaguely associated with aged care, yet it has taken over a decade for an alternative to be developed, let alone implemented. 

On the flip side is the opaqueness of just how much it costs to provide world class care, whether we actually value older Australians enough to want world class care for our elders and whether we can afford it if we do. 

We often hear individuals bemoaning the existence of the private or for-profit sector, and much criticism of the profits they may or may not be making. My view is that you cannot have a government policy that encourages private investment and a market economy and then not expect these companies to make a profit for owners and shareholders. To think otherwise is simply naïve, as is the notion that the not for profit sector isn’t doing exactly the same thing.  Making a profit or surplus from a business is not a sin, it’s actually how businesses continue to operate. They need to invest and renew, afford continually rising costs and receive a reward for their investment. The issue is transparency – or the lack of it – that drives the suspicion and derision that has plagued the sector.

A Failure of Delivery

While we continue to hear calls from older Australians that they do not want to live in large institutions, we keep building them. We hear from unions (and others) that there is simply not enough staff. We often hear words like “economies of scale” used to describe how aged care can be more efficient and yet we somehow forget that these are human beings we are caring for. They are not a cow in a feedlot, or a commodity or a “consumer”. They are Mum, Dad, Grandma or Grandad. My family, your family, our friends, our neighbours. 

Aged care is a business where the business is people. The government wants to spend the least amount of money possible, and businesses need to make a profit. The losers in this equation are the residents who live in these “homes” and the staff who bust a gut day in day out to care for them. 

When it comes to delivery, I always ask myself the same questions. How can this service provide quality care when:

• They don’t have adequate governance systems to operate
• They don’t have enough staff to physically do the job
• They have one Registered Nurse to more than 100 residents
• They have 1 activity person to keep 50 people entertained and stimulated
• They don’t provide appropriate education and training
• They don’t have adequate levels of supplies and equipment
• They pay their staff the bare minimum possible
• The service offers an environment that is well past its use by date, has multiple people crammed into rooms and more than 20 people sharing a bathroom like a caravan park.
• The food is cooked by untrained staff using the cheapest ingredients and served on a hospital tray.

Yes, this does not happen everywhere (far from it), but it does happen in enough places to keep teams of consultants and advisors gainfully employed for decades. I have seen all of the above repeatedly in the last 12 months.

A Failure of Regulation

Sadly, the largest culprit in the demise of aged care standards is the operation and performance of the regulator itself. Tasked to ensure the minimum standards of care and services are upheld, the Quality & Safety Commission has been woefully inconsistent, completely ineffective and the sectors own worst enemy. 

The Aged Care Act 1997 and its many amendments have become a fiction that has more similarity to Lewis Carrolls ‘Alice in Wonderland’ than reality. The current standards are almost impossible for providers to achieve with any reliability and just as impossible for the regulator’s assessors to audit.  

Notions such as does the ‘residents feel safe’ are a nonsensical subjective measure. I can live in a home for a year. For 364 days I can be perfectly happy and feel safe. Last night, a resident who happens to have a cognitive deficit came into my room and woke me up, frightening me. Today I don’t feel safe. Feeling safe, or happy, or supported, or content are not definitive consistent measures and can change day by day, hour by hour. You cannot take todays answer as a reflection of my life. But this is exactly what aged care audits do.

Having just spent 14 days in hotel quarantine I was most unhappy with the food. I had no choice, the food was not to my liking, it was served cold and I often went without the required equipment for me to eat it. I can equally go to a Michelin starred restaurant and be served a meal that I do not particularly like. That is life. Unwavering constant satisfaction is not guaranteed. It’s just not consistent with life. 

The failures of the regulatory system are, in my opinion, the leading cause of failure across the sector. The regulator has repeatedly failed to identify glaring non-compliance, sometimes for years, only to return and find it when there is a threat of media exposure or in the face of mounting complaints. They have failed to remove the bottom feeders from the sector that are a blight on all of us.

When I recently had cause to complain about the care of my relative, I was told by the delegate of the Commission to move her somewhere else. When I asked for details of a recent visit (a visit that I was not advised of despite being the guardian of a resident), I was told this is not information provided. What happened to transparency, open disclosure, the rights or residents and representatives to information to make informed decisions? It appears now the regulator has completely given up trying to address highlighted issues and now just tries to ignore them until you just go away. 

Posing leading questions at audit such as “others have told us that they don’t like the food, what do you think?” are inappropriate and deceptive. Telling education and quality staff that they will be sacked after the audit because providers “don’t pay for your positions” are just offensive. The personal views of assessors with no basis in legislation are irrelevant. I honestly do feel for some of them because their heart is in the right place but the lack of experience and knowledge of basic legislation is scary. Others are just downright nasty while some act like they are God.

The lack of transparency around decisions, who is issued Notices and Sanctions, who is appointed to address the non-compliance, what the actual problems are is another huge problem – these are not state secrets. I thought we operated in a model of continuous improvement? You aren’t supposed to be perfect. Residents and relatives have a right to know. Not 3 months down the track when the Commission decides to publish it. And not a redacted, sanitized version of the truth that is so vague you have no idea what the problem is. People living in the home deserve to be fully informed … your Charter of Aged Care Rights actually requires that.

How can we have situations where a home fails multiple standards, is issued with a sanction and then on appeal it all vanishes like it never happened? How do we repeatedly have homes receiving unmet outcomes only to have these reversed by the delegate because there is no evidence to support them in the first place? How do we now have homes being issued with Notices without even a visit by assessors, no evidence, no report simply because they have a COVID outbreak – and why do so many in the same situation go unscathed? It’s like Gorillas in the Mist. You know they’re in there but not quite sure where.

The regulatory system needs complete reform. Not just another name change. Not just a change of building. Not the same old people with new titles. Real reform. They, as much as we, need standards that are definitive, demonstrable, achievable, reflect the funding available and that can be audited with consistency. The dysfunction cannot continue. Older Australians rely on us all to get this right.