While the aged-care royal commission’s interim report highlights the need for reform, experts warn the government’s plans to outsource health assessments may only add to the crisis. By Rick Morton.
Outsourcing to hit ‘dysfunctional’ aged-care system
While the federal government digests the aged-care royal commission’s excoriating interim report, it is pushing ahead with a plan to privatise the workforce responsible for assessing which older Australians should receive government-funded care.
Experts fear the move will spell the end of “any meaningful direct involvement of geriatricians” and other specialists in the assessment process.
Advice to government from the sector has warned there is a risk of “de-skilling the assessment workforce through loss of clinical expertise and knowledge”.
As it stands, Aged Care Assessment Teams (ACATs) are charged with running the myriad clinical and psychological checks of the elderly who have applied for home or residential aged care.
The federal government recently released feedback from consultation on its pledge to strip these ACATs from the state system and farm the service out to the private sector. It’s yet to release tenders for the new service, which it wants to establish next year, but contracts for current state-based ACATs will expire in July 2020.
One senior member of an ACAT told The Saturday Paper they have “no confidence a lesser-skilled private workforce will deliver the quality in assessments required”.
He pointed out the ACATs are based in hospitals, “so there is that clinical governance and if a team member needs a new opinion from someone not on the ACAT, they ask.
“The [Health] department is demonstrating this delusional thinking that they can retain this level of co-operation with a private non-government organisation. With all the best intentions and goodwill, it’s just not going to happen.”
Medical specialists and aged-care researchers say outsourcing critical assessment teams would further strain an already “dysfunctional” aged-care system.
In an interim report released on Thursday, the Royal Commission into Aged Care Quality and Safety offered a censorious appraisal of such marketisation of aged-care services. This shift has been a bipartisan effort, propelled by multiple reviews, which, the commission lamented, “have not questioned the evolution of the aged-care system into one more reliant on ‘market forces’”.
“It is a myth that aged care is an effective consumer-driven market,” the report says.
It also found some issues facing Australia’s aged-care sector are so urgent they cannot wait for the commission’s final report, due in a year.
The report revealed there have been more than 270,000 cases of substandard care in Australian nursing homes in the past five years – figures self-reported by nursing home operators.
The commissioners pointed to the testimony of Health Department secretary Glenys Beauchamp, who “told the royal commission that ‘based on the evidence and information available to the Department … serious instances of substandard care do not appear to be widespread or frequent’”.
Their response: “We beg to differ.”
The report says the federal government must provide more home-care packages to reduce the wait for higher-level support. Beauchamp previously told the commission this alone would cost between $2 billion and $3 billion.
The commissioners also supported new regulations to minimise physical and chemical restraint, which came into effect in July, recommending the Commonwealth “respond to the significant over-reliance of chemical restraint in aged care”.
It heard such practices, the effective doping of residents in order to manage them, is justified in only 10 per cent of cases.
Elsewhere, the report says the “flow of younger people with disability going into aged care” must be stopped. “We see no reason to delay action in these areas,” wrote the commissioners.
The report comes after months of hearings that have raised concern about the viability of Australia’s aged-care system.
“On current trends, the entire system is under serious threat. And without fundamental change, we’re concerned the system will fail,” counsel assisting the royal commission Peter Rozen, QC, told the inquiry last month.
“… The Commonwealth also needs to be active. Funding from its aged-care workforce programs has been stripped … The Commonwealth’s failure to lead in aged care has contributed to the distressing outcomes for care recipients, their families and workers that you continue to hear evidence about.”
It is against this tableau that the Coalition is forging ahead with its new reform to “streamline” two current groups of aged-care assessors – ACAT and the Regional Assessment Service – outsourcing the work to the market.
Sources familiar with the proposal have described it as the federal government being “penny wise and pound stupid”.
In a witness statement to the royal commission last month, geriatrician John Maddison, president of the Australian and New Zealand Society for Geriatric Medicine, said the changes represent a “potential threat” to the availability of expertise in assessing aged-care recipients.
“Three decades of close association between ACATs and geriatricians will soon change following the Legislated Review of Aged Care 2017,” he said. “Recommendation 27 of this report proposes combining the Regional Assessment Service (RAS) and ACAT workforces, and as a result we do not anticipate there will be any meaningful direct involvement of geriatricians in this process once these changes are implemented. This remains an unintended and unrecognised consequence of this recommendation for which no mitigation has been articulated.”
The Department of Health has acknowledged that “some stakeholders believe a competitive model is unsuitable for assessment functions that focus on quality, consistency and equity of access.”
Despite these concerns, though, it is investigating the privatisation of this service through the creation of a “national assessment workforce” made up of contracted workers.
“Essentially what they are saying is they want to take the assessments back in-house and wherever you see that from a Commonwealth point of view you have to read it as privatisation,” one source who has been privy to government discussions told The Saturday Paper.
“The Commonwealth does not deliver services.”
Currently, ACATs across the country conduct some 200,000 assessments every year at a cost of $800 per assessment to the federal government.
Feedback released by the government shows there would be some cost benefits from combining the two teams, but the consolidation may create other issues.
In addition to gutting the assessment process of experience and skills, the sector has raised concerns about “conflicts of interest within assessment organisations … breaking existing relationships between assessors, providers and health services” and “unintended consequences of funding model and performance framework.”
As one aged-care specialist told The Saturday Paper: “We have a model for what they want to do and that’s the Regional Assessment Service. And they are all Certificate III TAFE students sitting at home saying yes or no to eligibility criteria.”
Regional Assessment Services, which only provides assessment for low-level Commonwealth Home Support Programme packages – a sort of entree to the home-care system – were established as private operators in 2015 by then Aged Care minister Mitch Fifield.
Those assessors are required to complete a “My Aged Care Statement of Attainment 2 – Home Support Assessor Training” and “National Screening and Assessment Form (NSAF) and Systems Training” through either a seven-day face-to-face or “online self-paced training” course.
One such assessor job advertised by Feros Care last week also asks for experience in “achieving contractual KPI and quality outcomes”.
The director of the Australian Health Services Research Institute at the University of Wollongong, Kathy Eagar, tells The Saturday Paper that “biting off this decision without any consideration of the broader system is really unhelpful”.
Professor Eagar, who was commissioned in 2017 by then Aged Care minister Ken Wyatt to review the funding classification system for residents in nursing homes, said the current ACAT system houses many medical and associated subspecialties such as psychogeriatricians, who specialise in dementia and cognitive decline.
Independent of her government work, Eagar was also asked by the royal commission to report on broader workforce deficiencies in nursing homes. The results revealed 58 per cent of all nursing home residents received an unacceptable level of care hours.
There would need to be a 20 per cent boost in total care hours across the country to bring providers up to an appropriate level, her research showed.
In senate estimates last week, the minister for Aged Care, Richard Colbeck, said he rejects assertions made by the royal commission counsel Peter Rozen that the Commonwealth is “missing in action”.
“We are quite cognisant … that there are some issues in the sector to be dealt with and we are working our way through dealing with those things,” he said.
Colbeck said he “will not reflect on … the comments of counsel”, as he hadn’t seen Rozen’s comments.
“I don’t watch every element of [the commission]; I have other things to do,” Colbeck said. “… I would agree with counsel that there … are significant issues around workforce that we will need to address.”
The Saturday Paper understands a final decision about when a streamlined national assessment workforce will begin has not yet been made. Bureaucrats are awaiting the signal from government.
Whatever shape this new assessment workforce will take, it will remain responsible for streaming people into government-funded care, either in their own home or a nursing home.
The royal commission has made it clear these systems have failed.
“By any measure, this is a cruel and discriminatory system, which places great strain on older Australians and their relatives,” its interim report says, referring to the long waitlists for home-care support. “… The aged-care system lacks fundamental transparency … The number of complaints against [providers] are not published. The number of assaults in their services are not published. The number of staff they employ to provide care are not published.
“… We have heard evidence which suggests that the regulatory regime that is intended to ensure safety and quality of services is unfit for purpose and does not adequately deter poor practices. Indeed, it often fails to detect them.”
At the same estimates hearing last week, Colbeck was asked if he is planning to respond to the royal commission’s interim report. “Well, it’ll depend on what it says,” he told the committee.
Now he knows.
This article was first published in the print edition of The Saturday Paper on Nov 2, 2019 as "Market assessments".
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