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After two-and-a-half years, the report of the Royal Commission into Aged Care Quality and Safety has landed. Its findings are clear: without a major overhaul and more resources, our elderly will continue to receive substandard care. By Rick Morton.

Aged-care royal commission final report

Stewart Johnston (left) and Andrew Knox with Clive and Barb Spriggs, outside the Royal Adelaide Hospital on December 9, 2019.
Credit: AAP Image / Kelly Barnes

Among the 2580 pages of the Royal Commission into Aged Care Quality and Safety’s final report, released this week, there is the magic figure: an extra $10 billion each year in Commonwealth funding, “at least”, that will be needed to bring the sector up to standard.

“At present, the Australian Government contributes around $20 billion each year to the cost of aged care,” Commissioner Lynelle Briggs writes in the report.

“Under our proposals, that amount is likely to rise to a figure of at least $30 billion.”

In last year’s budget, the Coalition forecast total aged-care costs hitting $26 billion a year by 2023-24, when the forward estimates end. Put another way, the additional injection of funding needed in the sector is enormous and it is needed now.

The commission’s final report comes two-and-a-half years after Scott Morrison first called the aged-care inquiry on September 18, 2018, in one of his first acts as prime minister.

Speaking then in his personal courtyard at Parliament House in Canberra, Morrison denied that in his previous role as treasurer he had stripped more than $2 billion in care subsidies from the sector since late 2015.

“No, I don’t accept that,” he said. “If people want to put questions, they’re not allowed to put lies.”

But the commissioners he appointed lay out the truth clearly in their report.

“Since 2015–16, expenditure per person in the 70+ years population (as a share of gross domestic product per capita) has been declining,” they write.

“Subsidy levels have been consistently indexed each year at a lower rate than provider input costs.”

In the two decades from mid-1999, the commissioners write, Commonwealth aged-care subsidies increased by 70.3 per cent. This fell far short of the cost of actually providing care, which increased by 116.3 per cent.

While Labor and the Coalition both favoured cutting the rate at which funding grew to constrain costs, only the Coalition – during Morrison’s stint as treasurer – pulled the money from aged care altogether and booked it as a saving in the budget.

These changes, coupled with successive government failures to address rationing of access to care, starved the sector of much-needed funding to address quality and staffing levels. The sector had been losing skilled workers and nurses in huge numbers since 1997.

As the commissioners write in the report, analysis shows that “2018–19 expenditure on aged care would have been $9.791 billion (53.9 per cent) higher if planning arrangements had been targeted to the population that generates residential aged-care demand, and if subsidies had been appropriately indexed.”

The report notes that because of the shortfall, older people “may not be able to access care when they need it, due to rationing of services, and when they do access care, funding may not be sufficient to meet the cost of providing the high quality care they need”.

Of course, the $9.8 billion figure is almost precisely what is now being recommended by Commissioner Briggs as an immediate cash injection to save the sector and help the elderly people who rely on it.

Should the upcoming federal budget offer anything substantially less than this $10 billion figure, aged-care sources say, the industry is ready for a fight.

“If the government does not address the core findings of this report, namely that the sector has been underfunded for the quality that is required, then this will become an election issue,” a senior member of the federal government’s informal aged-care advisory group tells The Saturday Paper.

Leading Age Services Australia chief executive Sean Rooney, speaking on behalf of the new Australian Aged Care Collaboration representing six of the largest provider peak bodies, tells The Saturday Paper they will be campaigning on the issue of aged-care reform.

“We have identified the 30 members of parliament who represent the ‘oldest’ electorates in Australia, by voter age, and recognise they have a unique opportunity to represent the needs of their constituents by fighting for a better aged-care system that will stand the test of time,” he said.

“We say to the parliament and the nation that the aged-care system is in need of a complete overhaul so it can be enabled and resourced to deliver the care and services that older people need.”

The government’s response to the royal commission’s report has already raised eyebrows in the sector, particularly the decision to release it on Monday in a last-minute media conference at Kirribilli House.

After two-and-a-half years of inquiry, journalists were given less than an hour to read the five-volume document ahead of the prime minister’s announcement.

A senior source within the royal commission tells The Saturday Paper that selective leaking of the final report to favoured media outlets ahead of its release was “infuriating”.

The stories stemming from the leaks said there were divisions between the commissioners on a path forward for the sector.

“[The leaking] tells us very clearly, before the public has even had a chance to see the findings, that they are willing to play politics with this historic moment,” said the source, who did not wish to be identified.

“That was a vindictive act and speaks volumes about the government’s commitment to this process.”

Others noted, too, that the landmark report was spat out without fanfare in the middle of a rolling series of crises relating to allegations of sexual assault in, or linked to, the federal parliament.

The release stood in contrast to the way the final volumes of the royal commission examining institutional responses to child sexual abuse were handed to the Governor-General on December 15, 2017, and tabled in parliament on the same day.

In time, those survivors were given a national day of apology in parliament.

Stewart Johnston, whose mother, Helen, was abused as a resident of the now-shuttered Oakden Older Persons Mental Health Service in South Australia around 2007, says it was a “horrific” wait for the report, after the early leaking of details last weekend.

Johnston’s story was one of the allegations of abuse that helped trigger the aged-care royal commission in the first place.

“I can honestly say that not knowing when it was going to be released or what it was going to say… we were just absolutely buggered,” he says.

“We haven’t met Scott Morrison. We have made multiple attempts, on behalf of the Oakden families, even before he called a royal commission but especially after he mentioned Oakden on the floor of parliament, and he has made promise after promise.”

Johnston says that former Labor leader Bill Shorten also stood up the Oakden families five times ahead of the last election.

Still, Johnston says he held some hope that Morrison would treat this royal commission as an opportunity to leave a legacy. That is until the prime minister started speaking on Monday.

“Once he opened his statement with 10 adjectives or whatever the hell he came out with, just one-liners… I think I lost faith there,” Johnston says.

“There are hundreds of thousands of families that are really hurting in this nation right now. And 700 people’s families just in Melbourne because of the Covid-19 bungle, which should never have happened.”

Johnston remembers the press conference when Morrison first announced the aged-care royal commission in 2018.

“It just showed the audacity of the man. It was just barefaced lying,” he said.

Johnston’s mother Helen was only in Oakden for a few weeks before she disclosed the abuse to her son. She told him she was being repeatedly slapped, dropped onto a toilet and told to shut up. He took her out of the facility and cared for her at home.

She died in 2014.

“She had no idea that anyone else was abused in aged care and I am so happy that she didn’t know the extent of it,” Stewart Johnston says.

“She went to her grave in 2014 believing that she was the only person ever and that no one else could ever have done something like that to an older person, and I’m glad of that.

“It would have torn her apart if she had have seen the extent of it.”

 

The extent of it, as laid out by Lynelle Briggs and her co-commissioner Tony Pagone, QC, is an invitation to despair.

Between 27,000 and 39,000 assaults go unreported each year, the commission says, because these are resident-on-resident attacks and not subject to requirements.

At least one-third of all nursing home residents and home-care package recipients have experienced “substandard” care. The regulator is timid, the Department of Health uninterested and the relevant ministers unwilling to “discharge their responsibilities” to steer the system towards quality.

“There is evidence before us that people in residential care may be left for the majority of the day without human contact, feeling isolated, forgotten or bored,” the commissioners write.

A number of the reforms considered urgent by the royal commission go to the heart of aged-care policies delivered poorly by the Morrison government.

Briggs and Pagone, for example, recommend that the Aged Care Quality and Safety Commission, the watchdog launched in January 2019, should be scrapped and “reconstituted”.

Quality standards intended to stipulate the type of care provided by aged-care operators – and against which providers can be penalised – do no such thing, the report says, and should be urgently reviewed.

These standards were only introduced in July 2019.

“The lack of objectively measurable standards in aged care is concerning,” the report says.

The commissioners zeroed in on the requirement that providers must have a workforce “that is sufficient, and is skilled and qualified to provide safe, respectful and quality care and services”.

“The lack of any clarity about the meanings of ‘sufficient’, ‘skilled’ and ‘qualified’ serves no one’s interests,” Briggs and Pagone write. “Not people receiving care, not approved providers and not the regulator itself.”

The government’s introduction of rules regulating the use of chemical and physical restraints, quickly introduced in aged care in early 2019 in response to media reports, should be re-written, the report recommends.

It notes that “deficiencies in regulation of restrictive practices have been identified as a significant human rights issue in Australia”.

“The Australian Government should amend the existing Quality of Care Principles to ensure that restrictive practices are only used in specified circumstances, based on an assessment of a person’s needs and informed by an expert accredited for that purpose,” the report says.

These regulations are important because of the widespread practice of “doping” or using physical restraints on nursing home residents to control their behaviour, which often arise from dementia and other cognitive or mental conditions.

Studies show that elderly residents who are frequently in pain, or anxious without a way to express this, can “act out”. But nursing home staff are so overworked they do not have time to address these issues. Instead, residents are kept sedated.

In a significant number of cases, residents are given Risperidone, which was developed as an antipsychotic to treat severe schizophrenia. All psychotropic medications carry the risk of increased falls and even death.

“In 2019, the Australian Government’s Aged Care Clinical Advisory Panel, comprised of experts from across the health and aged-care sectors, estimated that only about one in 10 of the antipsychotic medications and benzodiazepines used in residential aged care was clearly justified in the treatment of mental illness and some rare, acute psychotic manifestations of dementia,” the royal commission found.

So deep and wicked are the problems in aged care that only a completely rewritten legislative framework can solve them, commissioners say. This new act, replacing the Aged Care Act of 1997 and its amendments, should be in place no later than the middle of 2023.

If anything is to change, however, the aged-care workforce must not only grow in size but also in skill set.

Since 2003, the proportion of registered nurses in residential aged care has fallen from 21 per cent to 15 per cent. Enrolled nurses have dropped from 13 per cent to 10 per cent and allied health staff from 7 to 5 per cent.

Meanwhile, poorly trained and low-paid personal care workers have jumped from 58 to 70 per cent of the workforce.

“The message we have heard is clear: aged-care quality and safety is directly dependent on the number and quality of the people who provide it,” the commissioners write.

“It is clear to us that the quality of care that older people receive has been compromised because, all too often and despite best intentions, those people who work in aged care simply do not have the requisite time, knowledge, skill and support.”

By the middle of 2022, the royal commission has ordered the federal government to make a registered nurse mandatory on site at every nursing home for 16 hours across the morning and afternoon shift. By the middle of 2024, this requirement rises to 24-hours-a-day, seven-days-a-week.

Similarly, total staff time spent on every “average” resident each day must rise to 215 minutes within three years, 44 minutes of which must be registered nurse time.

“The current requirements under the Aged Care Act 1997 (Cth), where providers can judge for themselves what staffing numbers are ‘adequate’ and what skill levels are ‘appropriate’, have not prevented inadequate staffing nor substandard care and may have in fact encouraged those outcomes,” the commissioners write.

“This translates to an across-the-board increase in staffing of 37.2 per cent in total care staffing compared to current staffing levels. The percentage increase in minutes of care provided by registered nurses from the current average to what will be required in 2024 will be 22 per cent.

“We consider that this increase in residential aged-care staffing by over one-third by 2024 will be challenging but achievable.”

There is also an immediate recommendation that the Australian government increase funding for accommodation services in nursing homes – the basic daily fee, covering vital areas such as food, nutrition, laundry and sanitation – by $10 per resident, per day. A rough calculation suggests this alone will cost more than $800 million each year.

In a direct rebuke to Morrison’s cuts, the royal commission also says subsidy indexation must be pumped up from July this year, using a formula that captures a greater share of wage costs, and this should also be applied to the basic daily fee.

Commissioners Tony Pagone and Lynelle Briggs disagree on the precise form that the new administrative arrangements should take, but are a unity ticket on the substance of the reforms themselves.

Pagone recommends the entire system be removed from “ministerial direction” and put in the hands of a truly independent body, an Australian aged care commission. Briggs, for her part, believes this will take too long and cost too much to deploy. Instead, she recommends a major overhaul of the existing Department of Health and says the regulator should be delivered with a separate secretary of aged care in a standalone office within the department reporting to the secretary.

How the new system is paid for is a matter for government, although the commissioners suggest a combination of reforms to means-testing arrangements – as it stands, some low- to medium-income people end up paying more for their care than wealthy individuals. There is also the potential for an increase in the Medicare levy or similar hypothecated tax.

A levy worth $610 per person each year would raise almost $8 billion, not quite enough to meet the full cost of the proposals in the report.

Both Pagone and Briggs agree that an inspector-general of aged care needs to be created to keep watch over the development and maintenance of the new aged-care system.

That managing a quasi-market of providers is difficult is “not a reason for abdication of system governance responsibility by the Australian government”.

“It should not leave the system unattended and unwatched,” the report says.

Further, directors of aged-care companies should be held responsible for critical failures in their own services.

While the commission is deliberate in pointing out that staffing matters are the “principal causes of substandard care in the current system” and can be legislated to new effect, other cultural shifts are not quite as easy to deliver.

On this, and the other 148 recommendations, the commissioners have telegraphed a clear message to the Morrison government that it needs to move quickly.

“Poor policy, honestly and diligently administered, may cause serious but unintended consequences,” Briggs and Pagone write.

“Persisting with poor policy, in ignorance of its effect or in the face of clear evidence of its failure, is another matter.”

This article was first published in the print edition of The Saturday Paper on Mar 6, 2021 as "Royal commission: billions needed now".

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Rick Morton is The Saturday Paper’s senior reporter.