Understanding the Royal Commission into Aged Care Quality and Safety
By Zoe McDonald
During a community forum in Townsville in July 2019, a woman spoke of her father’s treatment before his death in a residential aged-care facility (Interim Report, Volume 3, p. 18).
“My father was found on the floor on a number of occasions when he had fallen, sometimes only wearing an adult nappy and shirt, and was eventually found with a broken ankle. We will never know how many times he fell, nor how long he was left on the floor each time, as the record keeping at the facility was not accurate.”
This account is just one of countless stories that surfaced in reports to come out of the recent Royal Commission into Aged Care Quality and Safety. The final report was handed down in February this year, telling the story of a systematic failure of care.
The Commissioners have labelled it a “shocking tale of neglect” in a “cruel and harmful system”, citing stories of maggots feeding on open wounds and videos of outright abuse (Interim Report, Volume 1, pp. 4-6).
Perhaps most disturbing is the systemic nature of the negligence. A 2020 research paper estimated around 39.2 per cent of people living in Australian aged-care facilities experience abuse in the form of neglect, as well as emotional or physical abuse.
It is a neglect that spans all avenues of care. Studies have estimated 68 per cent of aged care residents are malnourished, or at risk of malnutrition (Final report, p. 70). Other research has found 61 per cent of residents in 150 aged-care facilities were regularly taking psychiatric medication, despite it only being justified in an estimated 10 per cent of cases (Interim Report, Volume 1, p. 7).
Beyond the statistical evidence, there are the harrowing stories from carers and loved ones: pressure sores that deteriorate into severe septic infections, urine-soaked bedding, and staff run off their feet.
The overwhelming narrative is that we wouldn’t accept such standards for childcare, so why is it acceptable for our parents and grandparents?
Professor Nancy Pachana – a Professor of Psychology at UQ and clinical geropsychologist – says it’s a result stemming from Australia’s persisting issue with ageism.
“Ageism in society affects aged care because it has to do with the worth of people,” Professor Pachana said.
“This was seen a lot during the COVID-19 lockdowns, with people asking why they’re wearing masks if the old people might only live an extra three months anyway.
“We have to come to grips with ageing as a society, because eventually, we all age, and we will all die.”
So, what did the final report tell us, and what did it recommend?
In short, there’s a lot to digest – the summary alone is 115 pages. It's important to preface, however, the report's overwhelmingly negative focus is partly a product of its purpose: to find problems and fix them. Many older Australians have positive experiences in aged care, something which wasn't a significant focus of the report.
To help break the findings down, Contact spoke to UQ experts to better understand the key points, what’s missing, and what we need to do next.
Medical vs social model of care
The overarching outcome of the Royal Commission is that aged care needs to be ‘person-centred’ and ‘right based’.
This is a welcomed recommendation by the experts and authors of the UQ submission to the Royal Commission, who criticised the current ‘deficit model’ of funding, in which aged-care facilities receive more funding to treat unwell residents.
This, they say, disincentivises quality care and has led to the sector’s growing medicalisation, focusing on physical concerns instead of ‘whole-of-person’ care – including social and environmental health.
“You need to look not only at what a person has lost, but what they still have,” Professor Pachana said.
“Generally, in aged care, none of that is looked at.
“People with no history of mental health can go into aged care and develop depression – in some studies, up to 50 per cent – because their unique selves are not recognised within this system."
“It’s in the vernacular – ‘God’s waiting room’. Just waiting to die is a terrible mindset.”
The World Health Organization calls this ‘functional ability’, and it’s a combination of a person’s physical and mental capacity – ‘can I do and be what I want to do and be’ – with their environment.
“What we need to ask is: what can people still do and how can we support their level of functionality?” Professor Pachana said.
“Older people want to be somebody's grandparent, they have hobbies – they don't want to just be sitting around in a room.”
Aged care adapting to the resident’s needs is called the ‘social model’, according to UQ’s Professor Brenda Gannon, an international expert in the health economics of ageing. Professor Gannon is Director of Research at the UQ School of Economics and Affiliate Professor at the UQ Centre for the Business and Economics of Health.
While the care environment should reflect that many residents enter aged care with significant health issues, the focus shouldn't be on treatment, but rather the experience of the resident.
“In the medical model, you ask what’s wrong and you treat them. In the social model, it’s really about adapting society to the needs of the person,” Professor Gannon said.
“Think of it in terms of disability. If you have a disability, your workplace needs to adapt to you so you can come to work. That’s the social model, whereas the medical model focuses on treatment.
“Older people are not to be treated – they’re to be included into society.”
Image: kupicoo/Getty Images
Bring the families in
UQ experts agree with the Commission's recommendation that families should become more involved in aged care.
In their submission, they called for the establishment of Family Advisory Care Committees, much like school P&C associations, to create a space for loved ones to have a voice in aged care.
“A lot of residents in aged care are incapable of getting out, so you need to bring people in. Part of that is making it more attractive for people to come and visit,” Professor Wilson said.
“One way of dealing with that – and I’ve seen it work really well in some facilities – is you have a place for families when they walk in that says what’s happening and where you can find people.
“When people get dementia, and it gets harder to spend time with them, families often stop coming. One solution is offering families the option to help at mealtime in the dementia unit. If their loved one is doing particularly badly, they can help someone else.
“That’s worked really well – some families continue to come even when their family member has died,” she said.
Professor Pachana said it was also important to make the transition for families less daunting.
“A lot of people feel anxious when they make the decision to put someone in a nursing home,” she said.
“Imagine dropping your child off at school and the kid just went – no parent groups or anything – you’d be really anxious.
“They need someone to tell them that other people have gone through this, and for other families to show them how it works."
What does it mean for you and your older loved one?
The report has revealed a lot of cracks in the aged-care system. This can be worrying if someone you love is receiving aged care. But it has also highlighted what you can do: UQ experts have stressed the importance of family involvement in aged care. This includes visiting older people in care, but also asking the right questions: has mum had her teeth cleaned today? How often are her incontinence pads being changed?
You and your family are the people who are most invested in quality care, and in that sense, you become a regulator.
If you’re working (and if the government implements the Commission's recommendation), it means you could start paying a 1 per cent levy on your taxable income. This levy would feed into a pot of money the government distributes to pay for care.
If you’re an older person, the report has revealed a lot of concerns – but it’s also outlined pathways to change, like an independent pricing authority and a new regulating authority under the Australian Aged Care Commission. It’s also profiled potential new models of care, including the small group home models, where residents live in smaller settings with fewer people and maintain their possessions.
For all of us, it’s revealed that we need to look at ageism as a part of Australian culture. Australians need to think critically about how we perceive and treat older people, as it directly affects their health outcomes.
Why the free market failed and a new levy
The Royal Commission criticised the government’s faith in free market economics to foster innovation and efficiency through competition, which instead resulted in many of the issues presented in the report.
Professor Gannon said it was a reflection of the basic tenets of health economics.
“The free market is not the answer, as there’s an inherent market failure if there is supplier-induced demand,” Professor Gannon said.
“Supplier-induced demand is much like if you go to the doctor and they tell you to have 10 tests – you’re not really sure if you need them.
“Similarly, if aged-care providers are focusing on profits and numbers, there may be supplier-induced demand here as well – that’s when you need government intervention.”
Professor Gannon agrees with the Commission’s suggestion to introduce a new levy, to which taxpayers contribute 1 per cent of their income to a government-controlled fund that pays for care for older Australians.
While the Commission floated it as a ‘Medicare-style levy’, Professor Gannon warns against medicalised language, and prefers the term ‘long-term care insurance’, used in other countries.
“It was termed as a ‘Medicare-style levy’, and the media picked it up as that, but that’s the wrong way to look at it, because that’s a treatment model: Medicare is mostly for treating people when they’re sick.
“But the money is not just for medical care, it’s for long-term care and ensuring people can live a good quality of life for longer.”
Chemical and physical restraints never appropriate
Chemical and physical restraints were a central focus of the Royal Commission following reports of their systemic overuse in the aged-care sector.
Professor Wilson said it was a combination of staffing shortages and persisting ageism.
“Staffing is a big issue, and because a large proportion of aged care residents have dementia. While you don’t have to sedate people with dementia, it takes a fair amount of energy to distract them,” she said.
“I think people also see it as OK because they’re old, or because they’re attacking each other, which they do if they’re not being adequately cared for.”
Professor Pachana said despite clear evidence that restraint had detrimental effects, the practice continues because of claims around time and money.
“There is a huge amount of data that chemical and physical restraints have terrible outcomes – broken bones, asphyxiation, harmful cardiac effects,” she said.
“People say they don’t have the time or the money to deal with situations when restraint is used, but they have the time for people to get hurt, break bones and have cardiac arrest.”
Much like the overall model of care, she said we need to look beyond the individual, to the environment they exist in.
“Has the environment been set up in a way that it makes people very confused, feel that they’re not being listened to, that the only thing they can do is call out or hit someone?” Professor Pachana said.
“The feeling then is that they need to be restrained or sedated, when we know that psychological behavioural strategies can make a huge difference on many occasions when restraint is used.”
“I don’t understand how we feel like tying people up and leaving the room is an OK thing, especially when we have huge amounts of evidence from all over the world that we don’t need to do that.”
Image: Christian Langballe/Unsplash
What does industry say?
Chief Executive Officer of the Aged Care Industry Association Australia Luke Westenberg said it was easy to blame providers for the concerns arising from the Royal Commission, but it's important to understand the findings are sector-wide issues.
“One of the key things the Royal Commission highlighted was that problems with the aged care sector are systemic, rather than necessarily due to the individual failings by specific providers," he said.
"I think what it shows is that we need to look at the aged-care system more broadly – we have an ageing population, and policy settings that were adequate 25 years ago aren’t necessarily what we need to see now.”
He said that among the overwhelmingly negative picture painted by the Royal Commission, there were many positive individual experiences that weren't shared or reported on.
“I think it’s important to remember that the Commission was largely charged with looking for areas of improvement, which means obviously they would be giving a fair bit of attention to the problems," he said.
“You talk to people in the aged care sector who've been working in the sector for 20 years, and they still like it because of the difference it makes.
“For example, one of our members cared for a couple who lived in one of their facilities, and they had their 50th wedding anniversary coming up. So, the staff organised a renewal of vows ceremony for them, gathering their family and other residents.
“This is one of the things that motivates people to keep working in aged care – it’s one of the sectors where you can see you’ve made a difference by coming to work today, and not all jobs are like that."
Westenberg said experiences like the above were the untold stories of community and kindness that are often lost amid sector-wide reviews and reports.
“Part of the challenge is that with the Royal Commission making systemic recommendations, you need to find systemic solutions, and so these stories that happen everyday don’t always easily lend themselves to forming part of the recommendations.
"This doesn’t mean they’re not important – they’re the core of a lived experience of providers, staff and people who are given care.
"I think it’s very important to ensure those are being heard."
Like Westenberg, Professor Pachana says balancing the negative findings with positive stories like these is key moving forward and attracting a high-quality workforce.
“As a psychologist, I would say too little attention has been paid to what has worked well – everybody is focused on what went wrong or was inadequate," she said.
“I understand that, because there have been some really appalling examples, but there also has to be something for people to work towards, because you want to encourage the best people to work in the industry."
Where to from here?
It’s a long report with a lot of recommendations – implementing it will be difficult and requires strategic prioritisation.
UQ experts see education and research as part of the solution. Professor Pachana welcomes the recommendation of an Aged Care Research and Innovation Fund. She said that while UQ is leading the way as the first age-friendly university in the southern hemisphere, this attitude needs to be seen across the country.
“The data, both in Australia and overseas, says we're not training enough people to work interprofessionally and with specific expertise in older populations,” she said.
“In my own training, I was paired with a psychiatrist when we visited older adults in clinical settings, and we learned from each other.
“It was one of the most formative experiences in my training, and we need to prepare graduates in the same way.”
While change might seem far away, Professor Pachana said it was possible, pointing to the success of small group homes in the Netherlands in place of Australia’s large, institutionalised model.
Some aged-care providers in Australia have already taken the Dutch model on board, including a micro-town in Bellmere where residents live in houses with seven others and have access to a cinema, GP, grocery store, beauty salon, café and more.
Each house has a trained 'companion' to assist with meals and medication, and residents have around-the-clock access to specialist and allied health care.
“In the Netherlands, they pioneered the small group home model, and there is over 20 years of data suggesting it’s better for staff and for residents," Professor Pachana said.
“In these small group homes, it’s common for people to bring their possessions, even their pets. I once asked a nursing home physician in the Netherlands if they allowed people to bring their pets. He looked at me like I was crazy and said, ‘of course we do, why wouldn’t we?’
“You bring the familiar, it’s in a smaller setting, and they’re very inclusive of families.”
There’s a long way to go, but Professor Gannon believes the report is a pathway to change.
“I do think that this report is the right start. People are now more aware that all these things are happening, and they might consider it themselves.”
Image: interstid/Adobe Stock