Lack of Funds amounts to Elder Abuse: But neither Party is Talking about it

Dr Tristan Ewins

In a reflection in Saturday’s Age (11/5) Merle Mitchell explained that institutionalization in aged care left her without a home.  Institutionalized care can mean loss of social networks and community.  In her opinion, there was the feeling that death would be a better resolution for everyone.  Fortunately, though, she did not lose contact with all her friends, and that helped preserve her “cognitive capacity”.   She presses the case for a counselor for all residents and for staff. And suggests that if the effort was made to keep residents engaged that may enable stimulating discussions on all manner of issues.   Merle also enjoys extra exercise half an hour a day ; but that is an ‘extra’ that has to be paid for ($50 a day).    Many cannot afford it.  In the end some of the biggest problems are the lack of ratios, and of personal control over everyday life. With ‘institutionalization’ you get up when you’re told to ; you eat when you’re told to ; you go to bed when you’re told to.

Merle’s story is one of an extraordinary number being considered by the Aged Care Royal Commission.  Unless the process is somehow corrupted the Commission will almost certainly advocate for better ratios for nurses and staff. It will consider the quality of food ; the provision of privacy ; the provision of mental stimulation – whether through discussion of politics, philosophy, religion ; or if you prefer - discussion of the football ; and remembrances of years past.  Just sitting people in common rooms to stare at televisions is not the answer!


Better ratios would mean more time to dress and wash in the morning.  It could help ensure residents stay healthy and actually eat their food. Gentle exercise should be provided for everyone capable – regardless of cost. There must be a wide range of books, and increasingly internet access as well.  A nurse on site 24/7 is crucial in the case of emergencies.  And morphine must be made available to the dying.  (I have been told it’s only available in hospitals)  There must be outings for those capable.  And preferably facilities must include gardens where residents can relax and be at peace.  Personal choice must be extended as far as possible.

At home care must also be a viable option and there has been progress ; but some are still left waiting too long for packages. Staying at home in familiar surrounds full of memories is very important.  But again maintaining social engagement is crucial. Including several outings a week ; taxi vouchers ; gatherings with like-minded individuals ; in short – general quality of life.  The support of family is crucial in all this ; but some families neglect their elders (and some lack family as well) , and in such instances communities must step in to provide support and affection. Obviously not everyone can do that work ; only people whose hearts are ‘in the right place’.

A lot has been made of elder abuse recently.  And there are some shocking stories.  But Conservatives prefer to focus on individual instances and deflect attention away from SYSTEMIC ELDER ABUSE in the form of insufficient regulation and funding.  So far in the current election campaign neither side has had anything much to say about Age Care reform, and provision of extra funding.  The initiatives suggested here are crucial to the well-being of our loved ones ; but they come at a cost: probably billions a year.  Meanwhile Conservative PM Scott Morrison focuses on tax cuts for the already well-off and thinks he can hoodwink us with mantras on ‘economic management’.  Those tax cuts will also mean austerity ; some of which will hurt the poor and vulnerable.

Sometimes  Aged Care workers (mainly women) need better training ; and to retain the best workers a Labor government should subsidise Aged Care worker salaries – as it is doing with child care workers. It can be a grueling job ; but it is one of the most important jobs of all to care for the most vulnerable of all. Loved ones we would not forsake for all the world.  Those workers need respect ; and they need support.

Labor is bringing in money from tax reform ; closing loopholes and so on ; but is not yet committed to significant aged care reform.  Beyond already-mooted reforms it is emphasizing its attempt to outbid the Coalition on a Surplus.  But when the Aged Care Royal Commission hands down its findings it must urge Labor to somehow dedicate comparable funds to those made available for the National Disability Insurance Scheme. (NDIS)  (assuming Labor wins the election)  Even if it means imposing a dedicated-purpose, progressively structured levy.  The political parties have treated this issue like a political football for over a decade.   That has to stop ; and we need real action on Aged Care NOW. 

Shorten is beginning – tentatively – to ‘break the mold’ – on small government.  The sufferings of the aged ; and their need for love and dignity is too important to again “leave it until next time”. Morrison is a hypocrite ; parading his ’Christian credentials’  while preferring tax cuts to caring for the vulnerable.   But Bill Shorten needs clarity and resolve.  It is an argument he can win.  We’re talking about our loved ones here ; and possibly of our own futures.  Bill Shorten must foreshadow the necessary commitment of resources now ; or he must support an immediate shift of policy on funding, ratios and standards following the Aged Care Royal Commission.   Lack of funds amounts to systemic abuse of our elderly.  Elder abuse cannot be ‘fixed’ without the provision of extra billions every year. 

Aged Care Reform NOW.

The State of Aged Care in Australia Today - by Sharyn Ladiges

by Sharyn Ladiges  (ALP member and activist)

It’s been 20 years since the government brought in the Aged Care Act 1997 to deliver a new model of care for older Australians who could no longer live at home and required assistance with daily tasks. The act aimed to facilitate choice and independence for the elderly, and direct services to those with the greatest needs.

But the legislative change also coincided with an era of advanced ageing and more complex needs in our elderly.

People who had previously entered low-level residential aged care (then called hostels), are now cared for in the community. Once they enter aged care, they’re older and sicker than before, and have more complex needs. Since 2008, the number of older Australians admitted to a residential aged care facility has remained steady, but the proportion of people with high-care needs has progressively increased.

Older and sicker Australians

Currently, around half of people living in aged care have dementia, depression, or another mental health or behavioural condition. The proportion of older people requiring high care for complex needs, which includes assistance with all activities of daily living such as eating and bathing, has quadrupled from 13% in 2009 to 61% in 2016.

When the act was introduced, more emphasis was placed on supporting older people to remain at home for as long as possible. Now, the transition to permanent care only occurs once all options have been exhausted. The needs of the elderly population often outgrow the available community aged care support. This then requires an admission into one of Australia’s 283,000 (subsidised) residential aged care beds. As a result, our aged care facilities are increasingly functioning as hospices for the frail elderly with complex care needs.

The main flaw of the act was to repeal the legal requirement for all aged-care facilities to provide 24-hour registered nursing care to assess and manage resident’s changing clinical needs, wounds and unrelieved pain. So residents have minimal access to this. Too few have access to the necessary help from a geriatric medicine specialist (doctor), psychologist or social worker. And their families have minimal access to psychological and social support, and bereavement follow-up.

Why was the act introduced?

The 1997 act replaced two outdated and confusing 1950s laws to create a single statutory framework for Australian aged care services. It detailed the responsibilities of aged-care operators in relation to quality and compliance. It also empowered the relevant minister to set out principles covering matters such as quality of care, accountability and user rights.

The introduction of the act fuelled a much-needed capital works program funded by low interest bonds from older people entering residential aged care. This was meant to make aged care facilities more home-like, while also meeting care needs.

A major achievement of the act has been the amalgamation of hostels (social care accommodation for older people) and nursing homes (frail aged accommodation with 24-hour nursing care) into a single, user-pays regulated system. Now, people live in one institution, but are classified as having either low-care or high-care needs.

This was to provide older people with an opportunity to “age in place”. So, to have a seamless transition into higher-level care as lower-level physical care needs intensified; and to ensure people living in an aged care facility received all of their care needs in one location.

Major pitfalls of the act

The act’s repeal of the legal requirement for 24-hour nursing care reflected the social model of care underpinning the legislation. The idealistic yet impractical philosophy took the focus away from nursing and medical care. So now, the bulk of personal care is provided by a pool of untrained and unregulated aged-care workers supervised by a very small number of registered nurses.

Registered nurses employed in aged care are central to assessing, planning, monitoring and delivering complex care to older people living in these facilities. But there are too few registered nurses (and they are often managing the facility) so they have limited capacity to ensure the older person’s function, comfort and dignity is optimised, their mobility maintained and dependence minimised.

These skilled nurses also have few opportunities to ensure the resident’s family members receive the appropriate level of psycho-social and spiritual support they often need. Primarily because they’re dependent on the unskilled workers alerting them to changes in the resident’s condition or the families concerns.

Aged care facilities lack the clinical infrastructure of our hospitals. So, if a registered nurse is not on duty, there are few people the unskilled care workers can call for timely clinical review.

If the GP can’t be contacted and the registered nurse is not on duty, an ambulance will be called and the frail older person will be transferred to hospital for assessment.

What needs to happen

Numerous inquiries have highlighted the need for a skilled aged-care workforce to ensure older Australians have access to the level and quality of health care they deserve. These health care gaps persist largely because the act’s principles, while possessing the status of law, are not subject to the same parliamentary control and public accountability.

A new nursing skill mix model is urgently required in aged care to address the level of unmet health care needs. At a minimum, the act should be amended to stipulate appropriate staffing requirements for the delivery of direct clinical care, including the presence of at least one registered nurse at all times. As part of the skill mix, a higher ratio of registered nurses and enrolled nurses supported by a team of care workers is required.

The availability of a nurse practitioner, with advanced training and prescribing rights, and a geriatrician to all aged care facilities would do much to improve timely access to medical care. It’s also likely the addition of this tier of health professionals into aged care would reduce the need for unnecessary emergency department presentations. These are often distressing for the resident and their family, as well as being costly to the system.

Unfortunately, the act fails our most vulnerable members of society and their families by not providing them with the skilled nursing, medical and allied health care they require in their last year, weeks or days of life.

Afterward (by Dr Tristan Ewins, blog publisher)

Sharyn Ladiges has described the evolution of the Aged Care sector very well, and has made a compelling case for "a new nursing skill mix model" which would include a registered nurse on site at all times.  This has long been a core demand of Aged Care workers, nurses, and families. Also broader 'staff to resident' ratios are necessary to ensure all residents in high intensity care receive the care they need ; including regular turning to prevent bed sores and so on.

Arguably, though, we could do with a National Aged Care Insurance Scheme model involving relatively comparable resources as the National Disability Insurance Scheme  - but hopefully learning from any problems which have been experienced in the implementation of that model.  This would provide comprehensive services for all in need of any kind of aged care: ageing in place ; low intensity residential care ; high intensity residential care...

Firstly we need to get rid of user pays: for both high intensity and low intensity Aged Care (and 'ageing in place') ; and fund fully from progressive taxation.  User pays mechanisms have often been onerous ; have forced the sale of family homes ; have weighed relatively heavily on some working class households.   Aged Australians from all kinds of backgrounds should have access to the same very high quality Aged Care services as one another ; where no-one experiences relatively inferior quality care on account of socio-economic background.

Secondly we need to ensure *happiness* and mental health as well as physical health.  This means ensuring social and intellectual engagement for people of a variety of backgrounds and interests.  It could mean outings ; forums ; access to information technology ; creative and artistic activities ; listening to or even playing music ; mediated discussions ; access to books ; reading and discussing the papers, current affairs, the news ; watching and discussing films, and so on.  This needs to be addressed in both low and high intensity care, and for those 'ageing in place'.  Perhaps more effort and resources need to be put into addressing loneliness amongst those 'ageing in place' alone as well.  High quality food needs to be ensured for all as well ; as does privacy; and access to pleasant surroundings - eg: gardens ; where possible sunshine ; and so on.

Finally , we need to be taking a close look at the 'for profit' part of the residential aged care sector.  Private providers should not be gouging residents and families ; and the sector needs to be thoroughly regulated to prevent 'short-cuts' and so on to reinforce 'bottom lines'.  We need more emphasis on the state sector and on 'not for profits' ; and subsidising these to ensure the highest quality care for everyone.

Thanks again to Sharyn Ladiges for her informed overview of the development of the sector and the issues it faces today.