The For Profit provider only began recruiting non-executive members to the board of its Australian aged care business in August 2019, according to the Managing Director of Bupa Villages and Aged Care New Zealand Carolyn Cooper (pictured above).
For an hour-and-a-half, Senior Counsel Assisting Peter Rozen QC questioned Ms Cooper – an RN with over 40 years of experience in the health sector who was seconded as interim Chief Operating Officer if the Australian business between 19 November 2018 and 28 July 2019 – closely around the Bupa South Hobart case study.
The line of his questioning was not so much about the events leading to the sanctions at South Hobart as about how Bupa has changed its practices since then.
Ms Cooper – who was in the hearing room for the entirety of the Bupa South Hobart case study – said the decision to change the makeup of the board was based on the new Aged Care Quality Standard 8 around organisational governance and their learnings from the sanctioned facilities.
“Can you explain to the Commissioners firstly why that change was made?” Mr Rozen asked. “What is it about the experience that we’ve been looking at that led to that change?”
“I think it was clear from our situation that Bupa ended up in that there was a need for greater governance at the aged care board level and it became clear that those people that were .... as well as on the board actually had as part of their roles had actually knowledge of what was going on anyway,” Ms Cooper replied. “So, the board meetings were not as robust as they could have been and that’s why there’s been a review and a very clear direction from our chairman and our CEO that they want to see robust governance.”
“I take you to be saying that because the executives knew about the issue that is were being discussed at the board level, that by definition they wouldn’t challenge themselves about those matters,” Mr Rozen clarified. “Is that what you mean by a lack of robust discussion at board level?”
“That is one way you could look at it, yes,” Ms Cooper conceded.
The Managing Director was firmly focused on the initiatives the providers has since put in place in its Australian business, many imported from New Zealand, including ‘attitude’ testing for staff developed by Care Advantage and a new Fit and Proper Persons policy and framework to ensure directors and senior managers are suitable for their roles.
The company has also made changes to its Clinical Services Improvement (CSI) team (which Thursday witness Linda Hudec had headed up) which is now known as the Clinical Services and Compliance Team (CSC).
“There is a risk, isn’t there, with such changes that it’s essentially old wine in new bottles, you give something a new name and you therefore assume that it’s going to be a different outcome?” Mr Rozen questioned.
“I would say that that’s definitely not the case for this,” Ms Cooper stressed. “What’s actually happened is that there’s also many other changes.”
This team now includes ‘Quality Partners’, staff with a clinical background who work closely with a small group of around five care homes around five with the clinical teams and general managers.
The Senior Counsel was more critical on other issues, namely the 13 lessons that Ms Cooper had outlined in her original 60-page statement about what Bupa has learned from its experience at South Hobart.
“A number of the, if I may say so and without being disrespectful, a number of the lessons seem obvious in a way,” Mr Rozen pointed out. “Take, for example, you need to take the home’s layout into consideration when determining rostering and arrangements and so on. From your perspective, why did it take the imposition of sanctions for a number of these lessons to be learned? What was lacking there before, do you think?”
Ms Cooper put the difficulties down to the layout of the facility and the difficulty in recruiting staff in Hobart.
“Can I suggest three lessons that should be learnt from the experience, and ask you to comment on them?” the Senior Counsel put forward.
“The first lesson I suggest to you is that an aged care provider like Bupa can’t implement an across-the-board cost saving initiative that involves reduction in nursing hours without it impacting deleteriously on the level of clinical care as provided to the residents. Do you agree that’s one of the lessons to be learnt from the experience?”
“I think if you’re reducing hours below what is appropriate for the residents that are in that care home, yes, I would agree that that’s an issue,” Ms Cooper conceded.
Ms Cooper also agreed with Mr Rozen’s statement there was not enough consideration of both the acuity of the residents or the layout of the home when it came to implementing its strategies to cut nursing numbers.
The Commissioners (pictured above) had to have their say too – and they were both looking at the bigger picture.
“So, what’s the broader lesson?” asked Commissioner Tony Pagone. “I mean, I can understand some of the questions that get asked of you and of other Bupa witnesses in a sense put you in an awkward position because they’re quite pointed, but at a broader level without the point, that’s an example that you've given us about the rosters, but as a systemic question, how as a matter of system can we ensure that other organisations don’t end up with the detail being missed in the implementation of a care by care basis?”
Ms Cooper advocated for the broader use of benchmarking – and for it to be checked by the regulator.
“I’m reluctant to say there should be more regulation than there is but there are – there could be opportunities to actually look at how people were developing the rosters,” she said.
Commissioner Lynelle Briggs also asked if there was a place for longstanding staff to be involved in these discussions too – to which the MD agreed.
Mr Rozen pointed out there was one staff member at Bupa South Hobart who hadn’t changed: the GP Dr Elizabeth Monks.
“Her evidence was – I think I’m fairly summarising it, that her concerns which she was raising regularly and, in some detail, but she said they fell on deaf ears,” Mr Rozen said somewhat delicately. “That was her perspective. I’m not asking you to comment on the whys or wherefores of that, but more at a systemic level, it seems counter-intuitive that a doctor working wouldn’t be listened to when they’re raising concerns about clinical care. What’s been done within Bupa to ensure that those voices are heard?”
Ms Cooper says Bupa now has a ‘Speak Up’ policy (another policy?) which gives people an independent process to follow if they feel their complaint or concern is not being heard.
The MD said she would also welcome a requirement for providers to take the care needs of residents into account when making management decisions.
Ms Cooper also conceded there had been too much emphasis at Bupa on the financial drivers of the business (driven by funding changes, she noted) and its ‘Save A Shift’ policy was unrealistic to implement in homes that were already short on nursing staff.
“It’s not a policy that I would endorse,” she said.
The Senior Counsel also honed in on the fact that the 23 November board report for Bupa’s parent company where the sanctions at South Hobart were discussed had not listed the failure of its clinical governance as a consideration.
“You accept, don’t you, Ms Cooper, that the evidence that we’ve examined does strongly suggest that the clinical governance framework did not operate as it should have in the lead-up to the sanctions being imposed in October 2018?” he asked.
“Yes, I do,” said Ms Cooper.
“And specifically, that what looked – looks on paper to be quite a robust process of mock audits and clinical governance reviews and improvement plans to follow-up, despite the warnings being raised in the mock audits the problems weren’t addressed,” Mr Rozen went on. “Do you agree with that?”
“I do,” Ms Cooper repeated.
Ms Cooper revealed the company has changed the procedure for its mock audits (no detail on how), appointed a new Head of Risk and are looking to implement ‘health checks’ of homes – similar to the model described by Commissioner Briggs the previous day.
The Senior Counsel also questioned the new 2019 staffing model developed by Ms Cooper and former Head of Operations Davida Webb for its facilities, which provides for a minimum of 2.5 hours of direct care per resident per day and a 20% RN/80% carer mix.
Ms Cooper emphasised that this was not about “cost cutting” and was based on the 2.48 average hours of care provided by the Top 25% of providers in aged care accountancy firm StewartBrown’s benchmarking surveys.
However, the MD seemed to think this number was ranking providers based on care hours per resident per day.
“I suggest to you what they mean is top 25 per cent in terms of profitability,” Mr Rozen stated.
“That’s not anywhere that I’m aware of,” Ms Cooper denied. “That’s certainly not the understanding I had.” (Mr Rozen is right)
Mr Rozen also pointed out that under the research by the University of Wollongong led by Professor Kathy Eagar commissioned by the Royal Commission the Bupa South Hobart home, with its 22%RN/78% carer mix, would only receive two stars – an unacceptable rating.
“We need to make sure that there is sufficient funding for us to be able to actually meet things like a star rating such as that,” Ms Cooper argued in their defense. “I would like to see an increase in staffing, I haven’t been asked that but since I’ve got the opportunity to say it, it would actually be absolutely ideal if we could have more staff in the aged care sector. And I think it’s not just registered nurses, it is more carers as well.”
Disappointingly however, there was one question the Senior Counsel missed: did Bupa take up the recommendations of Dr Webster and Ms Wilson?
Fortunately, Bupa’s SC Jane Needham came to the rescue, requesting a few minutes with the witness to ‘restore’ Bupa’s reputation somewhat.
In response to her questions, Ms Cooper said the provider had found their recommendations useful.
“I think in amongst all the remediation activities across the business they have been included,” she said. “May not have been as quickly as they suggested this morning things could have happened but they absolutely were useful.”
Ms Cooper also added they have a new complaint management framework that came in mid-year to ensure complaints are processes within one business day; installed a new complaints manager; and ensure the board are receiving regular reports on complaints through the clinical governance risk committee.
Will they be successful? We will find out if the number of sanctioned Bupa facilities starts to drop.
Either way, it seemed like the MD came off lightly – and given it is Bupa’s second appearance before the Commission, it appears unlikely the provider will come under the microscope again.
