Scrutiny has never been greater with the recent Royal Commission investigations, demands on staff ever-increasing as they try to meet the new Quality Standards, and with big questions around the future of funding.  

While the spread of COVID-19 has shone an even harsher light on failures in policy and practice, it has also opened new impetus for action and could drive innovation and hope, according to national and international aged care experts speaking at the 2020  Wicking Trust Symposium on 14 October.

A two-hour online panel session on residential aged care asked: What’s quality got to do with it? Does loving care and quality of life have a place in aged care?  And how do we design and build the aged care system all of us want for ourselves?  

In a wide-ranging discussion, the expert panel stressed that safe care was not necessarily the same as quality care and that it must be guided by what its residents want and need.

It also urged that reform from Australia’s Royal Commission into Aged Care Quality and Safety “gets the balance right” between regulation, innovation and different models of care, so it can deliver a workforce that provides loving care and meet the growing acuity of residents.

Moderated by Associate Professor Colm Cunningham, Director of HammondCare’s Dementia Centre and a member of the Wicking Trust Strategic Review Panel, the discussion featured:

• Scottish dementia expert and author Professor June Andrews who led Scotland’s centre for Change and Innovation to foster improvement in delivery of health care

• Helen Grinbergs, 1st Assistant Secretary, Ageing and Aged Care, Federal Department of Health

• Ian Henschke, Chief Advocate for National Seniors Australia  

• Dr Stephen Judd, recently retired Chief Executive of HammondCare and an author of books on dementia care, aged care design and the role of charities

• Professor Susan Kurrle, a geriatrician who holds the Curran Chair in Health Care of Older People at the University of Sydney and is Clinical Network Director for Rehabilitation and Aged Care in Northern Sydney Local Health District. She was chief researcher on the ABC TV documentary series Old People’s Home for 4 Year Olds which recently won an International Emmy award.

Opening the event,  Grant Hooper, Senior Manager Granting, Equity Trustees, said Wicking Trust’s major grant program aimed to improve wellness and quality of life for older people and those with Alzheimer’s Disease by supporting organisations that are “well placed to effect systemic change in these areas”.

The annual Wicking Symposium recognises that grant makers cannot just allocate funds but “need to amplify and deepen impact by bringing together key people to share knowledge and information”, he said. Below are key themes and issues that emerged in the panel discussion.

Know what quality looks like

Prof Andrews talked about her early days working as a young nurse in a mental health facility, where she was shocked by poor practice but accepted it as “that’s how you do it”.

“You really can’t work towards quality unless you know what quality looks like,” she told the symposium.

A former head of the Royal College of Nursing in Scotland, Prof Andrews gave another example of a son and daughter looking for a care home for their mother. In the carpark of one, the daughter said: ‘it smells of urine’. ‘Don’t they all?’ he asked.

Given the very low expectations many people have of residential aged care, she worried that the “awful stories” through the coronavirus pandemic have “added to the social dread that many have about the very idea of being in a care home at the end of life”.

But she said the UK had also seen public celebrations of the dedication of many aged care staff during the pandemic, including those who “took up residence” in their facilities to keep residents safe.

As a result, she predicted an “uptick of people” who would consider working in the sector, “because they’ve seen what good looks like under stress, or what happens elsewhere that’s shameful”.

“We have to imitate the good people,” she urged, welcoming growing use in the UK of TripAdvisor-like apps to rate aged care facilities, and encouraging quality facilities to hold open days or have public cafes that provide opportunities for people to visit and “understand what good looks like”.
  
Panellist Ian Henschke urged those at the symposium to take advantage of the spotlight that COVID-19 has shone on aged care, so that is now “front of mind, front of society”.

His suggestion that it meant people may be prepared to pay more for better care, through higher tax or personal contributions, was a prospect that fascinated Prof Andrews, given that former UK Prime Minister Theresa May’s so-called “dementia tax” proposal appeared to help sink her leadership.

Increased personal contributions to aged care was, she said, a difficult question: the current generation looking at future aged care could well be able and willing to sell their houses to pay for it, “but what about the next generation” if they did not own homes at the same rates, she asked.

Helen Grinbergs acknowledged a lack of transparency currently in the system that she said needs to be improved and to lead to a “shared model of responsibility”.
 
Ultimately, she said, government is responsible for the way the system is funded and regulated and providers for the delivery of care, but the role of families is also important — “there’s only so many eyes and so many regulators you can have,” she said, urging also a focus not just on outputs but what is achieved for residents.

Deliver a better trained, valued, caring workforce

Workforce remains one of the biggest challenges for residential aged care to keep pace with increased acuity of residents. As in all aged care discussions, the panel heard debate about the mix of skills and roles required to provide safe, quality care, how and who best to recruit and train, how to deliver or mandate ongoing accreditation and how to best hold staff and organisations to account.

The panel highlighted the potential for a new cohort of workers to enter the workforce due to the pandemic, including young people now struggling for work in retail and hospitality and older workers who have lost jobs and may welcome the opportunity to retrain.
 
Ian Henschke said the low pay and low skills of the current aged care workforce reflect a “problem with ageism in our society” and he urged the introduction of systemic training, by bringing in an apprenticeship system, as well as a psychometric assessment to ensure the sector is staffed by people who like and want to work with older people.

“People are not just suffering poor quality of care, they are dying as a result,” he said, highlighting the tragic case of a South Australian woman whose appointed carer had now been charged with manslaughter due to neglect and abuse.
 
That case was “at the extreme end” of poor care but he asked what other sector would “provide a six-week online course and then say ‘off you go, deal with the most vulnerable in our society’”. Regarding infection control and dementia as optional subjects was “a major problem”, he said.

For Prof Andrews, decent wages for aged care workers is the key to better care, particularly given economic migrants often make up large numbers of the workforce — often because they will work for lower wages. “You can’t just exploit that forever without having to pay a price,” she said.

Dr Stephen Judd highlighted the risks of poor organisational culture, saying he could not understand how many aged care organisations in Australia managed with a staff attrition rate of 25 per cent, which should be closer to 10 per cent. He spelt out three critical workplace requirements: 

1. Believe: staff believe in what they and their organisation is doing
2. Belong: the organisation tells staff ‘what you are doing is valuable and I value you’
3. Achieve: staff believe they are achieving in their own work and in that of the organisation.
 
Dr Judd’s focus on staff retention was echoed by Prof Susan Kurrle, who said her mother had benefited from being cared for by the same staff at her aged care facility for more than two years.
 
“They know my mother really, really well,” she said. “We know that if you have a supportive employer, and you’re valued for what you do, then you are much more likely to stay,” she said.
 
But she warned: “you cannot have a health-related response from staff who are not health trained”, saying that clinical skills were not everything but their need also could not be overlooked. Helen Grinbergs said aged care workforce issues were not simply a matter of training, but also “the aptitude and attitude” of individual workers, the scope of practice offered to staff, particularly nurses, whether qualifications should come first or via on-the-job training, and how to manage ongoing refresher training, given that “if we don’t use the skill, we lose the capacity”.   The recent Federal Budget had introduced programs to encourage transition of practice nurses into aged care and post-graduate programs, but Ms Grinbergs warned such transitions cannot come overnight. She said rates of casualisation in aged care were actually lower than widely perceived, and a number of providers have very stable workforces. But she agreed that some are unstable and rely very heavily on agency staff and casuals. “Some of that comes back to culture and leadership of organisations as well,” Ms Grinbergs said.

Deliver more and better data

Panellists also highlighted the risks and costs of inadequate data around many aspects of the aged care system, including on individual health needs and their complexity, through to what services are being delivered and where and how quality is being measured or not.

In one powerful example, Dr Judd said Australia lacks accurate data on even the number of people who have dementia. Some estimates put the number at 422,000 now, expected to double by 2050, but he said the figures were “very rubbery”. 

Accurate numbers are critical, he said, particularly as international evidence shows a “levelling out” of incidence of dementia which could mean having to spend $10 billion a year less in health budgets on dementia care if the nearly 900,000 cases predicted in 30 years are closer to 600,000.

Ms Grinbergs said workforce data was also lacking, with the last workforce census and survey carried out in 2016, before significant growth in the sector. While there had been much concern about rates of casualisation and of staff working across multiple facilities, she said good data was also needed on levels of casual staff supporting older people in programs at home through Commonwealth Home Support and home care packages, and what training those paid carers have.
 
“It’s fair to say that we don’t have good data around (many) aspects of the aged care system, from the perspective of the person, their individual health needs and complexities around those needs, through to what are the actual services that are being delivered and are we measuring the right things in terms of quality,” she said. 

“Our focus at the moment tends to be on clinical indicators, we need to balance that with quality of life indicators as well,” Ms Grinbergs said.

Other wishful thinking for systemic change

Ms Grinbergs told the symposium that the last couple of years of working in aged care policy at the Department of Health had been some of the most challenging in her career, with issues raised by the Royal Commission already depleting confidence in the aged care system.
 
“And then COVID came,” she said.

The combination had highlighted tensions in the system and the need for reform, but had at the same time driven significant innovation, that the system needed to hold on to, she said.

Ms Grinbergs, the most senior Federal Health bureaucrat in the aged care area, said a  major systemic gap revealed in the pandemic was a lack of understanding in the health system of what aged care is, what it delivers, and how it operates — revealed in the way public health units went into aged care to support COVID-19 responses, “expecting it to be like a hospital”, she said.

“[Ensuring] the health system can better understand what aged care is and how to work with it is one of those future challenges.”

Dr Judd urged a stronger commitment to palliative care, to bring back hospices, introduce palliative care units in specialist nursing homes and rapidly increase palliative care in the home, saying acute hospitals “should be places for treatment not death”.
 
Currently, he said, more than half of Australians die in hospitals, and only 14 per cent in their own homes — about half the rate of the US, France, Ireland, and New Zealand. Apart from the comfort of people dying, “we can’t afford to build more acute hospitals over the next 20 years… just for people to die in.”

Dr Judd also urged regulatory change so “Dodgy Brothers” aged care facilities can be more easily closed down or face tougher competition from better facilities, so residents can “vote with their feet”
.
Better design and build of aged care facilities needs also to be built into government funding models, he said:  there will be no wholesale change if “the provider will get the same amount of money regardless”.

Helen Grinbergs said the Federal Government had given in-principle support to change how residential aged care places are allocated, but the how and when had not been resolved.
 
“My view is we need to do it sooner”, she said, but noting issues for areas like regional and remote Australia “which are thinner markets and (providers) may not choose to invest because they don’t see viability”.

Ask the people who are using aged care what they want

What’s quality got to do with aged care? That was the key question put by A/ Prof Colm Cunningham.

Ask the people who are using aged care, not their children, and particularly not aged care providers, was the response from Prof Kurrle.
 
They will tell you: they want a comfortable home, with surroundings, routine and care that allows them to keep their identity, their autonomy, and their social connections, to be as independent as possible, she said.

“They want to enjoy what they’ve enjoyed all their lives — that might be their family, their garden, their animals, a glass of wine in evening, sometimes it’s just being able to get outside when they want to.”

Prof Kurrle said there was evidence from around the world that the “cottage model of care”, even if it is designed within larger facilities, is better for older people generally and those with dementia particularly. They had also proven to be safer and better for infection control and emotional support in the pandemic, the panel was told.

“But aged care providers are still building and selling the traditional model of large institutional care,” she said. “My question to them and to all of us is: aren’t you listening?”

It is also important, she said, to beware first impressions. Prof Kurrle said she recently visited a multipurpose regional service that looked “incredibly institutional”, with a mixture of acute and aged care beds. But residents could see farm animals in paddocks outside their windows, staff were incredibly caring, and the local community was involved.
 
By comparison, one of her clients went into respite at a high-end aged care facility and lasted just five days, aghast at being told what to do and when to do it. “Her next words will stick with me: ‘I didn’t survive the war and two husbands to end up back at boarding school”.

Helen Grinbergs said one of the “most joyous experiences” she had experienced from an aged care perspective in recent times was watching ABC TV’s Old People’s Home for 4 Year Olds series, which showed the need to focus on the individual: “what are their social and emotional needs as much as their clinical needs and how do we get that balance”.
 
Australia’s aged care system does have “a big road ahead”, she said.
 
“The Royal Commission has made that very clear, about the big structural changes we need to make. At the same time, we need to get the balance right with regulation and the need to drive innovation and different models of care. That’s a real challenge for government.”