Senior Counsel Assisting Peter Gray QC (pictured above) has warned the challenges in providing health care services to those receiving aged care can only be solved if the Federal Government, States and Territories and aged care and health care providers combine their collective wills to push through reform.
For just over half an hour, Mr Gray noted the Counsel Assisting team had tested 20 propositions as possible solutions to failures in the interface between aged care and health care, and are now reconsidering aspects of these in light of the evidence this week.
However, recounting the stories of the direct experience witnesses and the challenges they face, the Senior Counsel concluded the need to fix these issues is self-evident.
“It puts people’s health and lives at risk and diminishes the quality and safety of their care,” he said.
The Senior Counsel then outlined a number of the 20 propositions and where the Counsel Assisting now stands on them.
That the system of funding primary health care for aged care recipients needs far-reaching reform:
Mr Gray stated the current fee for service model for GPs under the Medicare Benefits Schedule (MBS) clearly does not create incentives for the kinds of care needed by aged care residents.
“The weight of the evidence before the Royal Commission is that blended funding models are needed for people in aged care who have high level needs. Blended funding models would usher in new more proactive integrated and teams-based models of health care.”
Reflecting that many of the witnesses agreed funding was a significant barrier, the Counsel said the way primary care is funded and provided must change.
“Structural reforms are needed to the way primary care is funded for people living in residential aged care to introduce preventive care and care coordination.”
Noting that the Commonwealth is already exploring blended funding models for primary care, he added all the models raised this week will need to be closely considered and also take into account the changing workforce in residential care – namely, the expanding role of nurse practitioners and the need to expand the skills of RNs.
That there needs to be increased access to secondary care services for people in aged care through the State and Territory local hospital network led outreach services:
Mr Gray flagged many of the witnesses had supported this idea, provided there was flexibility to account for regional differences, the roles were clearly defined and there was adequate clinical governance to ensure continuity of care.
“In our submission, the systematic introduction of outreach services will need to occur in conjunction with a strengthening of primary care and a clearer and better enforced role for residential aged care providers taking responsibility for the provision of health care to the older Australians living in their facilities. In addition, specialist outreach needs to be supported by a realignment of responsibilities at the governmental level.”
A major undertaking – however, the Counsel surmised given the current gaps in providing specialist services to aged care residents, they should be an essential part of the system.
That specialists should be given incentives to provide greater levels of services into aged care facilities:
Again, Mr Gray noted there was general support for this idea.
That there should be greater emphasis on patients who are 65 years or over receiving rehabilitation services following a hospital stay:
The Senior Counsel recorded the State witnesses backed this proposition – provided there was funding.
That there should be performance indicators relating to the rate of ambulance callouts to aged care facilities:
Here, Mr Gray said there was opposition from some witnesses and caution from others (I’m guessing this may be a proposition that will be re-worked).
That there should be better data collected on use of State and Territory funded health services by aged care residents to inform policy monitoring and design:
The Counsel said there was “substantial” consensus on this issue – and support for the Counsel Assisting’s idea of an aged care identifier for the hospital data recorded by the States and Territories.
That older people’s health information must be better shared across the interface, particularly during hospital transfers:
Mr Gray stated that the Counsel Assisting’s propositions – that there be requirements for standardised clinical handovers when aged care residents are taken to hospital and returned to their facility and that rules are needed to ensure hospital discharge summaries are provided to facilities – both met with approval.
That there be interoperability between the health management systems in aged care and in health care:
The Senior Counsel reflected that witnesses had made a strong argument for live data between MyAgedCare and hospital systems as well as shared software with visiting GPs or joint use of the My Health Record system.
Finally, that the role of aged care providers needs to be expanded and clarified to support people in aged care to receive the health care they need and to ensure that there are no gaps and responsibilities for providing that care:
“The evidence suggests that there is a degree of uncertainty about what exactly aged care providers are funded to do when it comes to ensuring that care recipients receive medical care,” Mr Gray said.
“They are funded to provide nursing services but not services provided by medical practitioners. However, they are to provide assistance, that’s a quote, in obtaining health practitioner services under schedule 1 part 2 of the Quality of Care Principles. How far this goes is not clear.”
The Counsel determined while Department of Health Secretary Glenys Beauchamp’s evidence suggested the Department accepts the need to clarify these responsibilities, amending the legislation is not enough.
He said it is clear the roles need to be defined at the intergovernmental level – and that could include facilities appointing a medical director to oversee health services, providing consultation rooms and equipment for GPs, updating record systems and using telehealth services.
The Senior Counsel used the Counsel Assisting’s proposal for a care coordinator – and the disagreement between the witnesses about who should be filling this role – to make his case.
“Multiple witnesses argued that their role, their respective role, GP, nurse practitioner or facility nursing staff as the case was, that that role was the one best suited for care coordinator. This eloquently makes our point. There needs to be clarity about the respective roles of health professionals and aged care staff and designation of a care coordinator for each person in aged care who has high level needs.”
This clarity would also need to extend to the provision of palliative care services in facilities, he added, whether that be through an outreach service or in-house model such as Resthaven’s, and the need for facilities to assist residents and families in advance care planning.
Lastly, Mr Gray wrapped up with a quote from Professor Leon Flicker, who gave evidence on Thursday:
“**Currently, at a Commonwealth and at a jurisdictional State and Territory level decisions are being made to remove themselves from this area because it’s someone else’s responsibility, and that’s completely wrong. This is me in a few more years, this is you. This is all of us. And we should be trying our best to make sure that the standards of health care we have is as good as it can be and the quality of life of older people who are disabled, who have complex medical problems, that should be maximised at all times,” he read out.
In conclusion, the Counsel said the Royal Commission’s final recommendations can do much to focus the Governments’ attention on these issues.
“But in the end, it will require hard work and good faith negotiation between the respective governments and their officials. The outcomes Professor Flicker demands will only flow when the governments agree on these interface issues in the spirit of urgently improving the systems for the benefit of us all.”
A valid point – given the divisions in funding residential care, health care and hospitals, reforming this system will come down to political will.
Do our Governments have the drive to achieve change?
To quote Commissioner Tony Pagone, the hearings were then adjourned “sine die”.
