A pandemic throws a perfect mirror onto a society and shines a light on every crack. There is no better illustration of this than the light that COVID-19 is throwing on aged care homes in Australia and internationally.
Australian aged care was already in crisis and a subject of considerable community concern before the arrival of COVID-19. In response to serious and widespread allegations of abuse and neglect aired on ABC Four Corners, the government had moved in 2018 to establish the Royal Commission into Aged Care Quality and Safety. Its interim report, simply called ‘Neglect’, concluded that ‘substandard care is much more widespread and more serious than anticipated’.
This ‘crisis’ in aged care has been festering for at least the last two decades. Shaped by the Aged Care Act 1997, the Aged Care Quality and Safety Commission Act 2018 and numerous reviews in between, aged care has undergone considerable change in that time. Prior to the Aged Care Act, high level aged care was effectively part of the health system and much of it was delivered in old institutional style nursing homes. The new Act was meant to better reflect what people said they wanted – a more social, homelike model with better facilities and a less clinical feel. ‘This is a person’s home, not a hospital;’ became the catchcry.
In response, homes became more ‘home-like’ and the emphasis moved to social, not clinical, models of care. Nursing staff ratio requirements were abolished with homes simply required to provide ‘adequate’ care. The language changed to reflect this new approach. “Nursing homes” became “residential aged care facilities” (after all, having a nurse on the premises is no longer required) and the previous distinction between “low” and “high” care was abolished. State governments significantly reduced their role in providing and monitoring nursing homes and bed licenses were increasingly awarded to large national and multinational for-profit companies.
During these last two decades, both major parties have seen competition and the market as critical means to drive improvements in both efficiency and quality and both have sought to be in alignment with key industry and aged care consumer peak bodies. They have all shared a common belief that competition would drive improvement and that consumers would be empowered to make choices. More support to stay at home would be on offer and providers would be encouraged to be innovative in their service offerings. They have a shared view that rigid standards and regulations stifle innovation and responsiveness.
At the same time, population demographics and social values were changing. The baby boomers were moving into older age, were more financially independent, healthier and were better educated than the generation before. No longer was residential aged care a lifestyle choice. For the baby boomers, residential aged care is the place you go when you have no other choice.
Two decades on, Australia’s 180,000 residential aged care beds are occupied by people who cannot live independently, even with formal community aged care support, either because of physically frailty or dementia. We demonstrated this in 2018 when we independently assessed 5,000 people living in residential care. Only 15% are independently mobile. Most of this independently mobile group have dementia. One in two (50%) require mobility assistance while over a third (35%) are bedbound.
Yet aged care funding and governance has not kept pace with this development and the pendulum has swung too far. Drawing on the rhetoric of a social model of care, governments, providers and some consumer peak bodies have been on the one page in declaring that there is no need for mandated nursing or allied health staffing or for rigorous clinical standards. After all, they argue that aged care is not health care and that mandated staffing and clinical standards would distract from the need for the aged care facility to feel like a home and not a hospital.
While many homes provide good care, too many do not. On the funding side, aged care homes are now effectively funded for ‘low care’ for a resident population that is demonstrably ‘high care’. On the staffing front, only 15% of residents are receiving care that would be classified as 4 or 5 star in the 5 star public rating system used in the USA. The sector requires a funding increase of about 35% to bring it up to international benchmarks. Most providers want big funding increases but with no strings attached.
This context provided a perfect storm for the COVID-19 epidemic. Staffed predominantly by low paid, often casual, personal care workers and with residents receiving only 36 minutes of nursing time on average, many homes were simply unequipped to cope with an outbreak of COVID-19. Infection control should be core business in aged care, not least because of regular flu and gastro outbreaks. Yet adequate PPE and training in how to use it have been lacking in many homes. Of 626 private homes in Victoria, about 100 homes (with the number still increasing) have had an outbreak of COVID-19 and more than 1,500 residents and staff have been infected so far.
Despite the experience of the outbreak at Newmarch in NSW (where 56 residents and 34 staff were infected and 19 residents died), both the Commonwealth (as the level of government responsible for aged care) and providers seem to have been unprepared for the tragedy now unfolding in private aged care homes across Victoria. At the same time, the 178 public nursing homes in Victoria have not had a major outbreak. Even after controlling for size and location, this is an important difference. One fundamental reason is undoubtedly the extra funding and better nursing hours in public aged care homes regulated by the state government.
The government has created a new aged care controversy this week when both the Minister for Aged Care (Richard Colbeck) and the Secretary of the Department of Health (Dr Brendan Murphy) refused to provide a senate committee with a list of Victorian aged care homes with COVID-19 among either residents or staff. In declining this request, the stated reason was to protect aged care homes from ’reputational damage’.
Throughout the pandemic, it has been common practice, for good public health reasons, to name schools, child care centres, restaurants, hospitals and other venues where there has been a case. The decision to protect homes from ‘reputational damage’ is a powerful reflection on the relationship between Canberra and the private aged care industry. As a matter of good governance, it should not be the role of government to protect aged care homes from reputational damage.
However, in doing what they did, they also cast a shadow over every private and non-government home. Given that this is an industry that is 80% funded by taxpayers and that people’s lives are at stake, where is the public accountability? This is not about ‘blaming and shaming’. We are living through a pandemic and it is about the public’s right to know. That said, age care advocates took matters into their own hands and published a full list within the day. Aged care is increasingly a contested space.
A lot of hope is resting on the Aged Care Royal Commission which will now not report until the first quarter of 2021. It is a once in a generation opportunity to get aged care right. We cannot afford to keep getting it wrong.