The aged-care royal commission
On Tuesday afternoon, Sean Thomas Rooney appeared before the Royal Commission into Aged Care Quality and Safety in Adelaide’s Commonwealth courts building.
A day earlier, it had been widely reported that Leading Age Services Australia (LASA) – the organisation Rooney represents – had lobbied to scrub proposed regulation changes that would require aged-care providers to give “comfortable internal temperature” to their residents.
“This may be interpreted that all services are required to have airconditioning,” LASA wrote in its submission. “This needs to be clarified in the rationale and evidence section.”
After an 18-month consultation with industry, a revised draft of the Aged Care Quality Standards was released. In it, the offending phrase had been replaced with a vague requirement that nursing homes provide a “comfortable and safe service environment”.
Observers read this change as a sign large companies in the aged-care sector were mobilising to water down any proposed reform that may flow from the royal commission.
When Rooney appeared on Tuesday, counsel assisting Dr Timothy McEvoy asked him why the recommendation was changed. Rooney responded by objecting to the phrasing of the question, insisting his organisation had only been looking for clarity.
“I don’t think that we’ve said we wanted anything removed. What we sought in our response in the consultation process was clarification if this now required all aged-care facilities to install airconditioning,” Rooney said.
“It was not an objection to the standard. It was basically just asking, is this the interpretation that the standard is now looking to realise?”
During the exchange that followed, McEvoy noted Rooney’s organisation had succeeded in “clarifying the phrase out of existence” and asked the LASA chief executive whether the changes would require providers to install airconditioning for their residents.
“There are many ways to cool a room,” Rooney replied. “Airconditioning is but one.”
It was a small exchange over a minor detail but it provided insight into the operation of a large industry that has, for the most part, escaped public scrutiny.
On Monday, federal Health Department secretary Glenys Beauchamp was questioned about a single document from the department showing there had been 3773 “reportable assaults” in aged-care institutions during the 2017-18 financial year.
Asked how this number was put together, Beauchamp explained that under current legislation staff at aged-care institutions are not required to report assaults by patients with dementia, as they are not considered to have the capacity to know what they are doing.
This means the statistic only represents a baseline. The real number of assaults is likely to be higher.
Last week, the commission heard from the family of Bob Spriggs, who told how they had to fight to secure an investigation into the neglect of the 66-year-old man with Parkinson’s and dementia who had been living at the Oakden Older Persons Mental Health facility in Adelaide’s suburbs.
The Spriggs case, exposed through the advocacy of Maurice Corcoran and the investigative work of ABC journalist Nicola Gage, outlined a situation so extreme it blasted the issue of elder abuse within aged-care institutions into the national consciousness. The reporting led to follow-up programs with ABC’s Four Corners and eventually to the royal commission itself.
To date, the commission has received about 800 public submissions and responses from 902 providers of Australia’s 2695 approved aged-care facilities. These facilities house 207,142 people in an industry that receives more than $11.2 billion a year from the federal government to manage their care.
Every year, 57,769 residents – or about one in four – will die. By the time the royal commission has handed down its recommendations, and reforms are actually introduced, a whole new generation will have taken their place.
Such is the intergenerational dimension of the issue that Professor Joseph Ibrahim, head of the Health Law and Ageing Research Unit at Monash University’s Department of Forensic Medicine, says it’s critical this moment is not wasted.
While royal commissions are usually convened to examine serious cases of criminal activity or corruption, Ibrahim noted that in this case it was being used to blueprint the foundation of an entirely new aged-care system.
When the Aged Care Act was passed in 1997, it represented a vast improvement over what came before. Since then, though, the world has changed and Australia hasn’t kept up.
“The act came into being in 1997,” Ibrahim said. “I assume it took three years to negotiate. They would have started their thinking in 1994. It would have been written by people in their 40s or 50s, so they would have been born around 1940.
“Knowledge has changed. Practice has changed. Societal expectations have changed. And we haven’t addressed those.”
The problems within the aged-care system have long been known.
Annie Butler, federal secretary of the Australian Nursing and Midwifery Federation, gave evidence to the royal commission last week, where she described – among other things – an extreme case of neglect in which complaints of pain by an elderly stroke patient were ignored by staff. When an agency nurse investigated after growing suspicious, she found a catheter had “tunnelled into his penis”.
Speaking to The Saturday Paper, Butler described with a heavy sigh the struggle the federation had faced in order to get their calls for change taken seriously. “The federation has records of us raising our concerns at the time [the act came into being] because the funding model was changed. Funding for care was put into a general pool,” she said.
Coupled with other changes to the sector, what the act created was a fractious industry in which hundreds of companies operated with varying levels of skill, professionalism and interest.
“We’ve adopted business models rather than genuine social models of care,” Butler said. “There are some providers out there really trying to do a good thing but it is very much a minority. Too often, economic outcomes are the driver and not care outcomes.”
For years this represented the status quo, and it is only now that the federation’s proposals for staffing and funding arrangements are being looked at more closely.
“The reality is there’s no focus on the human rights of older people,” Professor Eileen Webb, of the University of South Australia Law School, says of the current act.
Citing reports that industry providers lobbied to water down regulations around airconditioning, Webb’s fear is this opportunity will be wasted.
“When the decisions are made, and the recommendations are made, and they’re trying to put it all into practice, that can’t be beholden to these really powerful business groups,” she said. “It has to be about care, and sometimes care can’t equal the massive profits the companies expect to generate. They’re going to have to have a balance.”
It is still early days for the royal commission into aged care, with the first block of Adelaide hearings drawing to a close this week. Another two-week block of hearings will follow in March before the commission goes on the road.
The commission will visit every capital city, as well as some regional areas, and the public will be able to make submissions until the end of June. Although it is only able to investigate claims of abuse going back five years, the commission has a broad remit to investigate issues relating to the restraint of patients, mismanagement, abuse and the operation of the industry.
Experts and industry observers warn that without sustained public interest and scrutiny, any reforms from the commission’s findings may fall by the wayside. Those currently housed or cared for within the aged-care system will not live to see the benefits of any reform. Instead, it is their children and grandchildren – people currently in their 50s, 40s, and even 30s – who will end up living in whatever system is created.
And yet, although this group is most likely to be affected, they are also the group least likely to be interested in the issue as the idea of growing old is distant or remote.
If the chance is missed to set up a fair, safe and effective aged-care system, Professor Ibrahim said, the complicated task of designing systems to provide public goods such as aged care, and the politics involved, mean there is unlikely to be a second chance to do so this side of 2050.
“If I don’t do all I can now, then whatever awaits me is what I deserve,” he said. “The system that is waiting for you is the one that we are building today, because it’s only going to be real in 10, 15 years.”
This article was first published in the print edition of The Saturday Paper on Feb 23, 2019 as "Ageing systems". Subscribe here.