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Wednesday, February 25, 2009

Another look at the Aged Care crisis - A call for kindness and justice




by Tristan Ewins


A synopsis of the problem

Few of us consider in our youth that we shall ever know the kind of frailty and vulnerability suffered by so many of our elderly. Even the more immediate prospect of dependence upon an under-resourced public health system is not enough to galvanise us into awareness or action.

Our politicians must accept their measure of responsibility. There is a systemic undermining of the tax base and its progressive structure. Successive rounds of tax-cuts are readily accepted as a device to appeal to strategic layers of self-interested voters. Rather than lead public debate, many are won over by the spirit of opportunism - as opposed to appeal to our “better angels”; the spirit of compassion and kindness.

The consequence, of course, is a surfeit of care, with the health, dignity and happiness of our elderly below what is acceptable. There are a few broad areas of concern to this paper: all broadly pertaining to the subject of rights for the aged. There is the question of aged care, including the responsibilities of hospitals, and the role of hostels and nursing homes. Also, there is the need for additional aspects of care: in areas such as dental care, energy, air conditioning, and heating.

All these concerns need to be addressed in light of Australia’s ageing population - and the structural fiscal impact this will have on future Federal budgets.

The impending crisis of the ageing of Australia’s population - and its fiscal consequences - were addressed by the first Intergenerational Report in 2002, and in another Intergenerational Report in 2007. Specific areas of concern include pensions, aged care, health care, and a narrowing taxation base.

The projected “fiscal gap” arising from such expenses was projected to be about 5 per cent of GDP by 2041-42. (2002 report), or about 3.5 per cent of GDP by 2046-2047 (2007 report). To get this in perspective, 5 per cent of GDP today is more than $50 billion. The difference in estimates here serves only to underline the fact that it is impossible to pinpoint any such “fiscal gap” almost 40 years into the future.

Government must decide between austerity and the “user pays” principle, or progressive taxation reform - with increased tax and social expenditure as a proportion of GDP. As the years pass the choices facing legislators will grow ever more stark.

The second (preferred) option implies “locking in” structural budgetary commitments to maintain services and pensions for aged Australians. The narrowing taxation base also implies that higher taxes will also prove necessary to maintain and expand the social wage and welfare state for all Australians.  The crisis of aged care in Australia has many dimensions, however. It is a problem of dire dimensions here and now - not merely “some time in the future”.

Insufficient staff skills and numbers

In correspondence with Charmaine Crowe, the Policy Co-ordinator of the Combined Pensioners and Superannuants Association (CPSA), I was informed of immediate crises in the standard and affordability of aged care.

Ms Crowe explained that one of the most essential elements of quality care are “staff numbers and skill mix”. Apparently “there are no mandatory staff/skill mix ratios”. The lack of trained staff comprises “the number one [reason] behind poor standards of care”.

Decent wages, subsidised training, recognised career paths, are all necessary to attract the best quality carers to the sector. Studies appear to back up these claims. A report on the aged care workforce by the National Institute of Labour Studies at Flinders University found that (in 2008):
Registered nurses in aged care are reputed to earn $250 to $300 a week less than their colleagues in acute care.

Furthermore, “the number of registered nurses in aged care [had] reduced from 21 per cent to 16 per cent”.
Residents requiring a higher level of care often need to be “turned” on a regular basis to avoid bedsores. And in case of incontinence, nurses need check on the conditions of residents regularly, and must be able to assist in showering and washing residents whenever the need arises. Diligence, and sensitivity to the dignity and humanity of residents is critical.

Against aged care as a business

According to Crowe, “for-profit” aged care is counter-productive. There is a contradiction, here, between an ethic of providing the greatest care and respect, and the motive of maximising profit and share-value. Ideally, there ought to be a mix of public and private providers - where private providers are run on a “not-for-profit” basis - managed by charities, churches and other community organisations.
Whatever the mix, though, measures of accountability and transparency are key.

Accountability

Crowe, speaking on behalf of the CPSA, condemned the accreditation and monitoring process for residential aged care in Australia. There are many dimensions to the problem: but the inability of vulnerable patients to hold their carers accountable - often because of dementia and other conditions - is a central concern.

According to the citizens’ group “Aged Care Crisis”, there is a deep and disturbing culture in areas of “aged care industry” whereby standards of care are often unmet, and even after warnings there is non compliance.
A parliamentary report “on the operation of nursing homes … mentioned 46 nursing homes not meeting standards as at June 30, 2008.” These numbers, however, are deceptive. Originally 199 homes “failed to meet at least one of the 44 standards”. The figure of “46 homes” only applied to “those still non-compliant at the end of the year".

In other words, apparently 7 per cent of homes “had failed to meet at least one of the 44 standards in the last financial year”. In addition, the Department of Health and Ageing, received many complaints. Out of 2,830 nursing homes, there were 11,323 complaints, 66 per cent of which were investigated. Areas of concern included: health and personal care 3,106 cases; physical environment 1,598 cases; communication 1,496 cases; personnel 1,255 cases; abuse 1,117 cases.

In one especially appalling instance there were residents in one aged care home who weighed less than 25kg. It is not uncommon for staff to allow insufficient time for vulnerable residents to consume their meals. Without conscientious staff, including registered nurses in sufficient numbers, often nursing home residents are left to starve. It is an appalling breach of care.

Crowe holds that the accreditation process “lacks vigour” resulting in poor quality of care. Currently, nursing home management has the option of “nominating the assessor” who will conduct the accreditation review: a clear conflict of interest. Reviews need to be more thorough; without such conflicts. And more prolonged and thorough visits should be made without the generous preparation times currently allowed.

Again, according to Crowe, nursing home managements currently can enjoy a “warning period” of up to three months for the more rigorous accreditation checks. It is not surprising, therefore, that in most such cases full accreditation is achieved.

Whether or not quality of care is sustained over the long term, however, is another question entirely.

Methods of finance

Crowe applauded the example of Denmark - whose social wage incorporates compensation schemes to ensure that the cost of care and disability are covered by the State. The principle is that the vulnerable should not be disadvantaged financially.

Denmark provides “rebates” for the disabled or frail - so that such people are not disadvantaged financially.
A further option, here, is for residents of nursing homes or hostels to receive a “targeted supplement”. This could assist pensioners and their carers so they can afford basic goods and services.

Those suffering from dementia and other debilitating conditions may no longer be in a position to hold the nursing home management accountable. Even in cases where families are passionately dedicated to fighting for the rights of relatives in care, maintaining accountability is a Herculean task.

Perhaps additional funding should be provided for a community and family advocacy group to ensure greater accountability. In Australia, there are several modes by which aged care fees are conducted. In our correspondence, Crowe related that there are a number of modes of payment.

Often residents are expected to provide about “85 per cent of the full aged pension” to meet the costs of their care (about $33 a day). Those on higher incomes may be asked to pay up to $118 a day.
Finally, low care hostels can charge a bond - at any rate they like - with the exception that residents must be left with no less than $35,500 in assets.

Importantly, those better suited to “low care” should not be driven into “high care” nursing homes, simply because they cannot afford the “low care” option.

Here, the system simply is not progressive enough. There needs to be a more graduated and progressive regime of fees and taxes.

Wealth and inheritance taxes - levied on individuals with assets of over $1 million - could help ensure that residents receive the care they need: while only being charged as much as they can reasonably afford. No longer would ordinary residents of ordinary means need fear being forced to sell the family home.

Are our elderly “a nuisance” for the health care system?

In the instance that elderly citizens do need care in hospitals, their rights and dignity needs be respected. They should not be shunned as “a nuisance”. I speak of a personal experience here, where a loved one was tied to her bed and drugged so as to keep her asleep. This was after a serious heart attack. Before her family had been contacted, the hospital authorities were already planning on moving her to a “high care” nursing home. And moves were made - also without consultation - to put down her pet cat. With family support, this person was later to spend several quality years in a low intensity care hostel, and made a partial recovery after rehabilitation. The beloved pet was rescued also. But without determined intervention by her family, this person’s future would have been very grim indeed.

Quality of life for the frail and the aged: dentistry

There are many other issues pertaining to “quality of life” for pensioners, including the frail and vulnerable. To begin: nursing homes rarely provide sufficient dental care. According to Doctor Clive Rogers, “nursing homes are passing accreditation tests even when their residents' mouths and teeth are so ravaged they risk serious illness or premature death”. Many such residents “[have] pus draining into their mouth [and] abscesses.”

Free dental care ought to be a priority for all Australians. But in the case of the most vulnerable Australians, our duty of care is even more plain. Dentists should be regularly commissioned to visit nursing homes and hostels: and should be “on call” for whenever the need for their services arises.

Quality of life: other elements

Beyond these essential concerns, there are other elements that would best be implemented to ensure quality of life for vulnerable and elderly Australians.

Residents should enjoy privacy with their own room - and to whatever extent possible - be in familiar surrounds.

Access to the “simple pleasures” of parks, gardens could potentially provide a significant improvement to residents’ quality of life.

Food must be of the highest quality available. And there must be sufficient attention from staff to ensure residents finish their meals, and do not waste away. Malnutrition and dehydration are disturbingly common.
Inadequate staffing levels directly contribute to this problem.

Opportunity for recreation, where possible, is also important. Television, music and radio should be provided - including in residents private rooms. And into the future - where residents are increasingly technologically literate - there should be access to internet services as well.

For those healthy enough to undertake them there should be regular outings, including visits to shops, churches or gardens.  For those who wish it, pastoral care should be provided. And social interaction between residents should be facilitated where possible.

There should also be provision of therapy services where required to maintain as much mobility as possible.
Heating and air conditioning for all nursing homes and hostels are essential. Given the kind of heat waves seen in Australia in late January 2009, this should be mandatory. Appallingly, no such common standards exist yet.

Finally - in an important aside - the role of carers needs be recognised and provided for. On average - with instances both of high and low intensity aged care - there is a government contribution of approximately $40,000 a year. Generous and just support for carers, here, could delay significantly formal admission into high or low intensity care.  It is rational - and it is right - that carers' pensions be dramatically increased. And the love of family can be such that even the most caring nursing professionals cannot provide.

Conclusion

In this paper I have attempted a comprehensive review of the aged care crisis - and have suggested a variety of options for reform.

Some might baulk at the assumed cost of the programs suggested. But in light of the suffering of our most vulnerable, I appeal to the common humanity of our legislators. They, too, will grow old one day. For all our sakes, such reforms would be very well justified indeed.

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