The main providers of residential aged care used to be religious, community-based and charitable organisations; the quality of care may have varied but owners were not motivated by profit. During the past decade, however, the number of privately owned aged-care facilities has grown at twice the rate of those in the non-profit sector.
A recent report suggested that average profits in the industry rose 40 per cent last year, while the time spent caring for residents declined by 7 per cent.
The federal government’s Aged Care Financing Authority paints a more complex picture. Although profits are up, some facilities are doing better than others.
Recent letters to the editor reporting medical negligence, neglect and inadequate personal care suggest that some facilities are prioritising profits over residents’ quality of life.
Ten years ago, a Senate committee held an inquiry into the sector. Its report was critical of the accreditation standards of aged-care facilities, finding them too generalised to effectively measure care outcomes. Given that the accreditation process enables aged-care facilities to receive government funding, it should not be a rubber stamp.
Unfortunately, vague phrases such as adequate nourishment and hydration, effective continence management, optimum levels of mobility and sufficient staff continue to be used.
More recently, a comprehensive list of quality of care indicators has been developed. This program is vital for encouraging continuous improvement and should be compulsory for all aged-care facilities; the government made participation voluntary.
A key to quality healthcare is a good staff-patient ratio. Without mandated ratios, many facilities operate with too few registered nurses and personal care attendants. Salaries are the main outgoings for an aged-care facility. Minimising staff numbers may maximise profits but it increases stress on those in charge.
Not surprisingly, there is a high rate of burnout among experienced nurses and managers, which lowers care standards even further. The rhetoric may be person-centred care, but the reality is somewhat different. On the morning shift, for example, residents are required to be toileted, showered, dressed, fed and medicated – all before 9am.
There is no requirement that these tasks be done thoughtfully; most staff are just too busy. Competent, honest and caring staff – managers, registered nurses, personal care attendants, as well as kitchen, reception and activities staff – are much more important than a nicely appointed bedroom or a lounge room with a coffee machine and grand piano.
Another problematic feature is the Aged Care Funding Instrument. This is used to pay subsidies based on each resident’s level of need. It, too, is poorly worded and often serves the interests of the providers rather than residents.
When a resident has been reclassified as requiring a higher level of care, staffing levels rarely change nor are extra services provided to the resident. The government recently introduced fines to curb a growing trend of incorrect, or false, claims for subsidies. Whether the fine of $10,800 for providers who repeatedly make false claims will act as a deterrent remains to be seen.
It is not only owners who may take advantage of residents. Some health care practitioners – GPs, dentists, podiatrists and so on – are also on the aged care gravy train. Recently, a dentistry service treated numerous residents at an aged care facility. Instead of charging a single “set-up” fee, each resident was charged this $90 fee on top of their bill.
Vocational providers are also claiming subsidies to offer aged-care courses despite some courses not meeting national standards. Age reporter Michael Bachelard has comprehensively illustrated how privatisation has turned vocational education “into a den of shonks and shysters”.
Former ACCC chief Graeme Samuel describes this waste of taxpayers’ money as the “inevitable consequence” of governments funding the private sector to deliver a public good.
Caring for older people with health issues such as dementia and incontinence is a demanding job that requires specific expertise. An “accredited” fast-tracked course does not equip graduates to work competently with older people, particularly those from culturally and linguistically diverse backgrounds and the gay and lesbian community.
Working with older people requires staff who, at the bare minimum, speak English fluently and are able to read and update care plans. Ideally, facilities would have staff who are kind and have a genuine interest in older people. Unfortunately, kindness cannot be taught or bought.
To ensure older people living in aged-care facilities have the best possible quality of life, relatives need to become more involved in their care. It is not enough to simply pay the fees and hope for the best.
My mother spent her last five years in an expensive facility in which the bond (a de facto interest-free loan) was $623,000. I visited her most days, so became acutely aware of the stresses on staff and the corners that are cut to maintain high profitability. In 2012, relatives at Mum’s facility were concerned about inadequate care. We documented incidents of negligence, incompetence, staff not telling the truth, bullying and racial vilification.
We also reported numerous thefts, though this was difficult to prove because victims were invariably people with dementia.
Fortunately, the owner responded positively to our list of our grievances. Most importantly, he replaced the manager. Good managers are the linchpins of a quality facility.
Towards the end of Mum’s life, only the most experienced staff were able to provide adequate care. Those with less than four months training did not have the required clinical skills. For two months, I sat at my mother’s bedside to protect her from inflexible routines and policies. I ensured she slept as long as she needed, and ate when (and if) she wanted.
After a week or so at her bedside, the manager asked me to stop interfering. I refused to budge, because I did not have confidence that staff could do their jobs.
The aged-care sector needs a shake-up. The key players have competing interests: residents and their relatives want high-quality care while owners focus on profitability. The government must increase regulation because the care of vulnerable people is too important to be left to the free market.
Aged-care facilities require meaningful accreditation standards, compulsory quality of care indicators, a more rigorous Aged Care Funding Instrument, better training of staff and mandated staff ratios. We need to ensure older Australians receive the quality of care they deserve.
First published in The Age on 8 January 2016