The (failing) aged care system we have in 2020 operates exactly as it was designed to – Part 1

 Outsourcing the government’s duty of care for older Australians has been at the core of structural failings in aged care for the last two decades. Covid-19 is just the latest in a long string of failures.

“It’s the system operating as it was designed to operate. We should not be surprised at the results.”

This statement was made by Peter Rozen QC as part of his opening address at the Royal Commission into Aged Care Quality and Safety hearing into the response of aged care to Covid-19. He went on to say that “the Covid-19 pandemic has starkly exposed all of the flaws of the aged care sector which have been highlighted during this Royal Commission”.

The four day hearing that began on 10 August was a powerful, and at times fiery, spotlight on the structural failings of the aged care system. It was also an illuminating display of the tensions and the conflicts that sits behind the tragedy that initially unfolded in aged care homes in NSW and has continued into Victorian aged care homes as Covid-19 has taken hold.

It was not like anyone should have been caught in surprise. The Covid-19 pandemic had rolled across Europe several months before it hit Australia and many thousands of residents in European long-term care homes had died. By March, the pandemic had arrived in Australia. But it was already too late by then for Australian aged care.

Structural failings in the aged care sector needed to be addressed well before Covid-19 if the sector was to have any possibility of effectively preventing and containing outbreaks in aged care homes. They weren’t.

Under the now very outdated 1997 Aged Care Act, successive governments have outsourced the care of older Australians to private aged care providers. Despite providing around 80% of funding (the other 20% being consumer contributions) and being the regulator, the Commonwealth guidelines for Covid-19 left it to aged care providers to manage as best they could and the Commonwealth lacked (and still lacks) the clinical governance systems and policy framework to effectively manage the pandemic in aged care.

Outsourcing the government’s duty of care for older Australians has been at the core of structural failings in aged care for the last two decades. Covid-19 is just the latest in a long string of failures.

This is not to suggest that there is no role for the private sector. There clearly is. But we need to understand and plan for aged care as a social responsibility and a public good. While providers may be in the public or private sector, every aged care provider is providing a public service that taxpayers are largely paying for. At the end of the day it is our government, not providers, that is accountable for aged care.

Outsourcing in aged care extends to the deregulation of the workforce. There is strong international evidence that the quality and safety of aged care is driven by total staff numbers, staff skill mix, staff continuity and clinical governance. I gave evidence at the Royal Commission into Aged Care Quality and Safety in October 2019 that 56% of aged care residents are in homes that would rate only one or two stars for staffing in the USA ‘Nursing Home Compare’ five star rating system.

There is already strong international evidence that the best predictor of the ability of a home to manage a Covid outbreak is the number of registered nurses they employ.  Most private aged care homes did not have, and still do not have, enough skilled clinical staff to manage a Covid-19 outbreak.

Outsourcing has also resulted in a lack of public accountability for funding. Government (taxpayer) funding has not kept up with the changing needs of residents. Equally, there is no requirement for providers to spend the taxpayer funding they receive on care. The Commonwealth did provide additional funding for the aged care sector for Covid. But there was no requirement that it be spent on additional staff and no requirement to account for what it was spent on or even if it was spent at all.

At the same time, many homes are reporting that they have spent considerable additional funds on both staff and PPE. For this group, the additional funding was apparently inadequate. However, in the absence of public accountability for funds, it is hard to verify either Commonwealth claims that the planning and funding was adequate or providers claims that it was not.

The Aged Care Quality and Safety Commission (a statutory Commonwealth agency) surveyed aged care providers during April-May about their preparedness for a Covid-19 outbreak. Some 99.5% reported that they were ready with more than 40% reporting they were ‘best practice’. Newmarch was one of these.

A parallel survey was conducted by the Australian Nurses and Midwives Federation in April-May of 1,980 nurses and other workers in for-profit, not-for-profit and government aged care homes. Up to 80% reported no increases in care staff; only 77% reported updated or implemented infection control procedures for staff; less than 40% said their aged care facility was prepared for a Covid-19 outbreak; and less than 30% said their aged care facility had enough supplies of PPE.  The contrast cannot be more different between this picture and the Commonwealth view that adequate planning had been undertaken and the sector was ready.

Underlying many of these structural failings is perhaps the biggest one of all – aged care and health care are managed and governed as separate systems with the Commonwealth fully responsible for aged care and the states and territories for both public health and public hospitals. An effective Covid response in aged care required an effective integrated health and aged care strategy. That integrated approach was missing before Covid and is still a vital missing link.

These structural failings meant that the aged care system was set up to fail before Covid-19 even arrived.

Part 2 tomorrow.

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Professor Kathy Eagar is Professor of Health Services Research and Director of the Australian Health Services Research Institute (AHSRI) at the University of Wollongong. Professor Eagar has undertaken extensive work in the aged care system over the last two decades. Most recently she led the design of the new Australian National Aged Care Classification and funding model for residential aged care and undertook research commissioned by the Aged Care Royal Commission into the adequacy of residential aged care staffing.

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