Aged care issues may not be popular, but they should be treated with the same concern we have for mental health or disability, writes Dr Linda Calabresi
It certainly looked pretty swish from the outside. The newish aged care facility which had recently become the residence of one of my dear elderly patients.
In her 90s, Yvonne had worsening dementia and was very frail, but had very much resisted leaving the family home.
However, the time came when she needed 24-hour care and supervision, and the search was on for an appropriate facility. While location, layout, food and furnishings were all important, the number one priority was care. Yvonne was a high falls risk and quite anxious, with multiple comorbidities – she needed to be watched, helped, nursed and looked after.
And that’s what this place offered. Even though it was at least 40 minutes from my practice and this meant Yvonne would need another, more local GP, all the marketing material suggested this facility would fit the bill.
As you might have guessed, things didn’t go entirely as planned. While the people working there were apparently lovely, there just didn’t seem to be enough of them. Promised activities didn’t happen. Physio, though scheduled, didn’t occur. Showering happened sporadically. Delays in answering buzzers saw Yvonne repeatedly try to get to the toilet by herself, resulting in falls.
At this stage, the family had not yet found a local GP to assume Yvonne’s care and they were still bringing her (in a wheelchair) to the surgery every few weeks. Not ideal, I know.
One afternoon I thought I’d pay Yvonne a visit. I trekked off and found this very new-looking, architecturally lovely two-storey building. Courtesy of the receptionist at the front desk, I located Yvonne in a private room on the first floor. On the way there, I passed two cleaners attacking some carpet stain (best not to ask!), but no other staff.
Yvonne was comfortable, sitting in a chair in her room watching television. I spent about 30 minutes with her. No-one else came in.
Following the visit, I went to check the med charts and write in the notes. The nursing station room was locked. I knocked, no answer. I walked the entire stretch of that first floor – at least 30 residents – but the only staff I could find were the two cleaners. They helpfully told me the nurse was probably on a break. And that was it. I left.
Now as much as this was frustrating for me, I’ll get over it. More importantly, this is a frightening example of extraordinarily poor care. If Yvonne had fallen, I know for a fact that she would have laid where she fell for at least 30 minutes, and probably a good deal longer. And I know this isn’t an isolated case.
Did you know that there are currently no Australia-wide mandatory minimum staff-to-resident ratios in aged care? We have them for childcare centres, kindergartens, schools, and public hospitals, but not for what must be surely one the most vulnerable populations in our community.
According to a report from the Australian Nursing and Midwifery Foundation, published in 2016, residents in Australian aged care facilities receive an average of 2.84 hours a day of actual caring. This falls well short of the Internationally recognised standard of 4.3 hours a day.
There is also no pre-requisite skill mix, no minimum percentage of registered nurses, or even enrolled nurses, in these facilities where complex medical conditions and multiple comorbidities would have to be the norm.
This is not to say that the personal carers are less kind or less caring, but they are simply not trained to, not only administer medical care but also to monitor the medical condition of these residents, which is often an important component of the job. It is little wonder that last year’s Aged Care Survey done by the AMA found that 35% of doctors currently attending patients in aged care facilities planned to cease doing so within the next two years, citing lack of suitably trained nursing staff as one of the main reasons.
Has it always been this bad?
Apparently not, but it has been deteriorating for over two decades. It seems the rot started to set in back in 1997 with an amendment to the Aged Care Act. Prior to this, aged care facilities, were required, by law, to dedicate a fixed percentage of the government funding they received to care, including salaries for nurses. The funds could not be used for non-care staff, property maintenance or be counted as profit.
Once that restriction was lifted, staffing levels and the staffing skill mix became the target of the accountants and “efficiency experts”.
Over the past few years, the decline in appropriate and qualified staffing in our aged care facilities has become increasingly untenable. In addition to the Nursing Foundation, pressure is being applied by some consumer groups, doctor groups and the occasional vocal individual to our political authorities to make the necessary legislative changes to ensure a decent level of care.
In true political fashion, the move towards improving the situation has started with the government establishing a taskforce, the “Aged Care Workforce Strategy Taskforce” in late 2017. This taskforce is supposed to be examining a range of issues including staffing, skill mix and minimum training requirements. I’m sure it is all “due process”, but do you get the feeling that true reform becomes increasingly elusive with every new committee, roundtable, advisory group, summit, report and review.
The real problem is that we have so few champions for this cause. These elderly residents usually don’t vote. They don’t recover. They are not cute nor tragic. They are not the subject of telethons, fun runs, red noses or daffodil days.
But while aged care issues may not be popular, they should be at least as important as issues mental illness or the disability scheme. We are talking about a population of citizens who are vulnerable and who are in need.
As medical professionals we need to lend our voice to the demand for safeguards for our elderly patients. At the very least, we need a minimum staff-to-client ratio and care by suitably qualified staff. Yvonne, and the thousands of residents like her, deserve no less.
