“A shocking tale of neglect”: Royal Commission’s Interim Report delivers searing assessment of Australia’s aged care system – and calls for fundamental overhaul

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Australia’s aged care system is “woefully inadequate” and in too many cases denies the basic human rights of older people – and Government, providers and the community should all shoulder the blame, the Royal Commission into Aged Care Quality and Safety’s Interim Report has found.

Ominously titled ‘Neglect’, the three volumes – which were completed by Commissioners Richard Tracey AM, RFD, QC (pictured above left) and Lynelle Briggs AO (pictured above right) and is damning from the first paragraph of the 10-page foreword, called ‘A Shocking Tale of Neglect’.

“The neglect that we have found in this Royal Commission, to date, is far from the best that can be done. Rather, it is a sad and shocking system that diminishes Australia as a nation,” the Commissioners write.

Initial impressions

The tone of the Report is revealing. The Commissioners could have ‘played it safe’ and simply presented their findings matter-of-factly – similar to the Commission’s background papers.

Instead they have gone for an inflammatory and scathing approach that is far more likely to attract media – and Government – attention (and indeed had some members of the media tweeting excerpts within 15 minutes).

Given Commissioner Tracey was the Commissioner who labelled the system “cruel and unkind”, the language used suggests he did – as Commissioner Briggs said – have a major role in shaping the message of the Interim Report.

Many of the words used – “cruel”, “harmful, “shameful”, the list goes on – are more suggestive of his courtroom experience than her bureaucratic background.

While there are no specific recommendations, there are three areas identified for immediate action before the Commissioners table their Final Report in November 2020:

  • to provide more Home Care Packages to reduce the waiting list for higher level care at home (clearly a dig at the Government for failing to act on the national prioritisation queue);
  • to respond to the significant over-reliance on chemical restraint in aged care, including through the seventh Community Pharmacy Agreement; (a swipe at the GPs who prescribe the medication); and
  • to stop the flow of younger people with a disability going into aged care, and speed up the process of getting out those young people who are already in aged care (another jab at the Government).

The layout of the Interim Report

The bulk of the Report is in the first 272-page volume which addresses the main information and conclusions the Commissioners have reached so far.

This volume contains ten chapters – seven of which flag recommendations for reform to be included in the Final Report:

  • An Overwhelming Sense of Loss – which tells the aged care story through older people’s experience of the system from direct evidence and submissions;
  • Finding the Door – which describes how people find out about aged services;
  • The Lottery – which details the current regime for the waiting list for home care;
  • Elders are our Future’ – which explains the challenges involved in providing culturally appropriate, safe and quality aged care to Aboriginal and Torres Strait Islander people;
  • Restrictive Practices – which covers the use of physical and chemical restraints;
  • Workforce Matters – which identifies some of the problems with recruiting and retaining aged care staff; and
  • Falling Through the Gaps – which recounts the plight of younger people in residential care.

Aged care out of the spotlight

The Report highlights a number of areas of concern, starting with the fact that many of the cases of substandard care brought to the Commissioners’ attention were well-known to both providers and the regulator.

“Why has so little been done to address these deficiencies?” they write. “We are left to conclude that a sector-wide focus on the need to increase funding, a culture of apathy about care essentials, and a lack of curiosity about the potential of aged care to provide restorative and loving care – all of which is underpinned by an ageist mindset – has enabled the aged care system to hide from the spotlight. This must also change.”

Home care comes in for particular criticism, labelled a cruel and discriminatory system”.

“It is shocking that the express wishes of older people to remain in their own homes for as long as possible, with the supports they need, is downplayed with an expectation that they will manage. It is unsafe practice. It is neglect.”

Residential care is not immune from reproach either, with the Commissioners singling out the need to make the transition into care less traumatic for residents.

“It will involve finding a way to bring the outside world into residential care homes, or taking those in care out,” they state. “We will delve deeply into these matters in our Final Report. In the meantime, we encourage the Australian community and the aged care sector to work with people in care to harness their ideas and to develop solutions on the ground.”

Lack of data – and transparency – an issue

Like the hearings, lack of data – and the lack of transparency that comes with it – again emerges as a theme.

“The combined impact of the evidence, submissions and stories provided to the Royal Commission leads us to conclude that substandard care is much more widespread and more serious than we had anticipated,” they say.

Poor wound care, poor continence management, “dreadful” food, high numbers of assaults, common use of physical restraints, widespread overprescribing and inadequate palliative care are all marked as major quality and safety issues.

“It is shameful that such a list can be produced in 21st century Australia,” they write. “At the heart of these problems lies the fundamental fact that our aged care system essentially depersonalises older people. A routine thoughtless act – the cup of coffee placed too far from the hand of a person with limited movement so that they cannot drink it, the call buzzer from someone left unanswered, the meal left uneaten with no effort to help – when repeated day after day, becomes unkindness and often cruelty. This is how ‘care’ becomes ‘neglect’.”

275,000 cases of substandard care in five years

The Report also reveals the responses from providers to the Commission’s request for information about cases of substandard care over the five years to June 2018 issued last November resulted in 274,409 instances being reported – including almost 112,000 occasions of substandard clinical care and close to 69,000 occasions of substandard medication management plus around 80,000 complaints about substandard care.

“How does the aged care sector respond?” the Commissioners ask rhetorically. “Not very well.”

The Commissioners conclude complaints to providers often go unresolved and the case studies before the Royal Commission suggest many times providers are reluctant to take responsibility for poor care on their watch.

“It is disturbing that the aged care sector is not sufficiently mature or professional to listen to feedback from those who use and observe its services at close hand, particularly when the regulatory system appears so distant and ineffectual,” they state bluntly. “Some providers of aged care have appeared before the Royal Commission to be defensive and occasionally belligerent in their ignorance of what is happening in the facilities for which they are responsible.”

Particular criticism is also reserved for the regulatory system, which the Commissioners concluded “appears to do little to encourage better practice beyond a minimum standard”.

“We were flabbergasted to hear that, until recently, it was routine practice for large sections of the reports of accreditation audits of services conducted by the Aged Care Quality and Safety Commission to be generated by computer assisted text,” the Commissioners say. “In other words, the same positive words prompted by computers were used over and over again. Computers cannot determine quality; only people can and should do that.”

Workforce rates a mention

The Report highlighting heavy workloads, poor pay and conditions, patchy education and training and a lack of leadership.

“Major change is necessary to deliver the certainty and working environment that staff need to deliver great quality care.”

The Government pays 80%, so is aged care a Government service? 

 “It is time for a reality check,” the Commissioners state seriously.

“The aged care sector prides itself in being an ‘industry’ and it behaves like one. This masks the fact that 80% of its funding comes directly from Government coffers.

Australian taxpayers have every right to expect that a sector so heavily funded by them should be open and fully accountable to the public and seen as a ‘service’ to them.”

The Commissioners do note they have come across some positive stories – but these are few and far between.

“It seems that these providers and staff are currently succeeding due to their own passion and dedication. The aged care system provides no incentive or encouragement for these achievements. In short, they are succeeding despite the aged care system in which they operate rather than because of it.”

Need for fundamental reform

The Report concludes the system is in need of fundamental reform and redesign – not just “patching up”.

“In due course, we will recommend comprehensive reform and major transformation of the aged care system in Australia,” they promise. “We will chart a new direction for the sector, bringing a clear sense of purpose and of quality, and a renewed focus on compassion and kindness.”

In conclusion, the Commissioners state: “We intend to put older people first and to give them a voice”.

The Report also puts the Government in a sticky situation with its three suggested actions.

Health Minister Greg Hunt and Aged Care Minister Richard Colbeck last night issued a statement:

 “The Interim Report and the Royal Commission’s hearings to date tell us some aged care providers are falling far short of delivering the safe, high-quality care expected by senior Australians and their loved ones,” it reads.

“We acknowledge that the Government also has work to do and will consider and act on the Royal Commission findings, whilst noting significant reforms are in progress.”

Scott Morrison responds today​

The Prime Minister appeared on Macquarie Radio’s 3AW this morning to say he will find the cash by Christmas for the three key areas the Commissioners want action, namely home care wait lists, chemical restraints and younger people in aged care homes:

“We will be making a response on those issues by the end of the year. One of the reasons I have been waiting for this report is because I wanted that it inform the final decisions we were going to make around in-home aged care funding before we finalise the mid-year update.”

Summary​

Nobody has come out looking good, with another 12 months to go until the final report is released.

Meanwhile the sector needs $2B in cash for the next 12 months or more weekly aged care homes will ‘hand back the keys’ and home care operators will walk away.

You can read the full report HERE.

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