State health representatives have argued aged care providers need to step up and take responsibility for ensuring their residents have access to health care services – but the Commonwealth needs to provide the funding to match and the legislation to enforce it.
In a session that ran to one-and-three-quarters of an hour, Senior Counsel Assisting Peter Gray QC questioned the panel of four State health officials: Dr Nigel Lyons (pictured above left), the Deputy Secretary of Health System Strategy and Planning at the NSW Ministry of Health; Dr John Wakefield PSM (pictured above right), the Director General at Queensland Health; Dr Christopher McGowan (pictured below right), the Chief Executive of the Department of Health and Wellbeing at SA Health; and Dr Andrew Robertson CSC PSM (pictured below left), the Assistant Director-General and the Public and Aboriginal Health and Chief Health Officer at the WA Department of Health (flanked by their legal representatives), around a number of the propositions being tested by the Commission this week.
Unsurprisingly, the panel were largely supportive of the measures being put forward by the Royal Commission around care coordinators, outreach services for specialists and palliative care, hospital transfers and rehabilitation – but they had some caveats.
In particular, the group pointed to the need for the roles and responsibilities of providers in delivering health care services to aged care residents be more clearly defined – and for facilities to provide a care coordinator.
Dr Wakefield says it is clear the Commonwealth is responsible for aged care and primary care and the States for hospital care, but the execution and levers have failed to deliver.
“The challenge I think we’re facing is the system is perfectly designed to deliver the results that we get. The system is a provider-driven market which fails significantly in my own State. Its dependence on primary care through a provider model of a basic fee for service means that unless you’re enthusiastic, it’s highly unlikely that a general practitioner will choose to provide the sort of services to residential aged care that’s necessary, and there are many places in Queensland where GPs are not present. So I think – I think if we – if we start off with determining what does a reliable, safe, high quality service look like to residents of residential aged care, then I think it looks very different to what we have now, which is essentially a provider-driven market fee for service model.”
Dr McGowan agreed, adding that even if the care model moved towards improving access to rehabilitation services, providers should be accountable for the coordination of residents’ care.
“In the event that they were transported to hospital, then the hospital would take over clinical governance for the duration of the acute visit,” he stated. “I’m more ambiguous about the rehabilitation side of it, should that be in a subacute service that’s run by the State, it should be the State’s responsibility, but I also strongly believe in rehabilitation in situ back in the home in which case it would also move to the residential aged care facility.”
The panel also agreed their state-based outreach services into aged care facilities have been fairly successful – but argued there are a number of issues including funding that would need to be addressed before the national rollout being put forward by the Royal Commission.
Dr Lyons pointed out that outreach programs were set up to prevent unnecessary hospital admissions, not as a long-term care solution.
“I think it’s important to think about that in the context of a redesign of the whole system, rather than imposing a solution that currently exists as being established for a different purpose,” he said.
Dr Wakefield agreed.
“This has been done against the tide of funding incentives,” he explained. “In creating CARE-PACT [the Queensland outreach services into residential care], we get hit twice. We, first of all, have to pay for a service which, technically, is the – it’s certainly in the current arrangements – is the responsibility of the Commonwealth, i.e., providing primary-type care in residential aged care facilities. And, secondly, because it’s successful in reducing work in the hospital, hospitals forego revenue because that’s how hospitals get funded – by doing stuff in hospitals. So, in terms of the will to do this, I think that the funding lever is critically important; as I said, it’s necessary but not sufficient.”
He added that the skilled workforce may also not be available, particularly in rural areas.
The panel did give a tick of approval to the Commission’s plan for standardised requirements for clinical care information to be transferred when residents are sent to or from hospital – but like previous witnesses, pointed to the need for a direct interface for sharing information.
Dr Wakefield noted that Queensland Health’s viewer enables all hospital information including discharge summaries, medications, and results to be available to GPs and subject to a legislative change, soon to paramedics and aged care nurses.
As a result, they currently have data on around 25,000 aged care residents – compared to the 5,000 residents in My Health Record.
“I think the challenge for all of us at the moment is that GPs have access to My Health Record but the aged care provider may not, and so how do we address that issue about either a link with My Health Record to the aged care portal or some other mechanisms to ensure that the aged care provider have systems where they can access that information as well as the GP,” Dr Lyons added.
“If you want systems to be able to talk to each other and you want a national approach to that, you’ve got to get some agreement about what data will be transferred and how that’s defined.”
“Why isn’t there already an obligation binding on the aged care side and binding on the hospital side requiring this information to be shared upon clinical handover?” the Senior Counsel quizzed. “Have the governments just never got together and agreed upon it?”
Dodging this awkward question somewhat, Dr Lyons responded that the system is not the same as the one 10 or 20 years ago.
“The residents who are in care are very different,” he said. “What has been invested in by various governments whether it’s Commonwealth or States is also very different. So, I think what we tend to see happen over time is that the evolution of the system and the policies that surround that and the funding levers that are used over time are not fit for purpose anymore.”
Commissioner Lynelle Briggs also made a telling comment about where her thoughts lie – namely, that delivering health care into residential care is everyone’s responsibility.
“Ideally, we would work through the roles and responsibilities and allocate them accordingly,” she stated. “But I don’t think any country in the world has managed to do that successfully, and there’s always got to be a bit of shared responsibility in many different areas. Would you agree with that?”
“Absolutely,” agreed Dr Lyons.
The panel wasn’t keen on all of the Senior Counsel’s propositions. Like the facility managers the previous day, Dr Wakefield cautioned against monitoring facilities’ rates of ambulance callouts unless the indicators are transparent and paired with other indicators.
He warned it could have “unintended consequences” by creating a perverse incentive for facilities to not call Triple 000.
“I think what we need to be very careful of is that we don’t – you know, residents also have a right to access and get benefit from the acute hospital sector when they need it,” he said.
The group was also skeptical about the Commission’s proposal for an aged care identifier for residents who are taken to hospital.
Dr Lyons said the States have already had discussions with the Commonwealth around the need for linked data for all Australians to monitor the effectiveness of services, but these conversations have not progressed.
Mr Wakefield added that all of the data is already supplied by the Commonwealth to the Australian Institute of Health and Welfare (AIHW).
The Senior Counsel wasn’t going to give up on the idea though.
“Short of an elaborate data-linking project, I suggest it would be a simpler matter to have a flag and to simply ask the Commonwealth for that information or, indeed, ask the patient in question, or their representative, are they from a residential aged care facility, so that that data could be captured in a – in effect, a useful way, so that data analytics could be performed upon it; isn’t that right?” he quizzed.
“We’re doing a project now to make sure that we can better identify, through more sophisticated means, working with our ambulance service but also our hospital admitted data collections, to get better clarity have that,” Dr Wakefield responded. “Well, actually, as I said, that requires a significant change to the way people do work and record information. My argument is why would we need to do that when we already know, the system already knows? It’s just that the two parts of the system don’t talk to each other.”
No surprises there.
