Is the royal commission ultimately failing the aged?

A genuine redesign of the aged care system is not achieved by doing more of the same thing

---

Recently the Royal Commission into Aged Care Quality and Safety released its Interim Report making a key observation: the aged care system has deep and entrenched systemic flaws.

Key systemic failures include that the system:

• is designed around transactions, not relationships or care
• minimises the voices of people receiving care and their loved ones
• is hard to navigate and does not provide the information people need to make informed choices about their care
• relies on a regulatory model that does not provide transparency or an incentive to improve
• has a workforce that is under pressure, under-appreciated and lacks key skills.¹

The commission has promised that its final report will deliver recommendations for a whole-of-system reform and redesign. The intentions are laudable, but the language is highly ambiguous. Reform and redesign have entirely different meanings.

Reform equals “tinkering at the edges” of the current system or framework, whereas redesign is the courageous step of drawing a line in the sand and drawing up a new and different framework.²

The latter is clearly the only way out of the current mess.

The emerging responses look more like reinforcing the causes that resulted in the failures that now need fixing.

Government uses convoluted ways for its ministers to shift their responsibilities – both a convenient way to take credit for success and shift blame for failures.

A series of agencies have put the onus of getting the aged care system fixed onto the Aged Care Quality and Safety Commission.

Early evidence would suggest that the commission’s newly created quality standards reflect the areas in the system where “real change” is required: consumer dignity and choice, ongoing assessment and planning with consumers, personal care and clinical care, services and support for daily living, organisation’s service environment, feedback and complaints, human resources and organisational governance.³

As an aside, the commission’s continuous use of the economic term “consumer” is disturbing as it endorses and reinforces the prevailing transactional nature of aged care. Residents, patients or aged persons are much more appropriate terms as they set up the framework of the culture that allows the emergence of relationships and resident/person-centred care.

We use the term care in aged care to signify our understanding that the aged care system is ultimately dealing with patients – patients actually means “the vulnerable” and stresses that care providers have a special professional responsibility to those they look after, both in terms of meeting their needs as well as ensuring that they are not exploited or abused.⁴

But other than the semantics, the areas highlighted for attention cannot be criticised. However, some of the responses to a number of the major issues exposed in the royal commission appear less well thought out, suggesting a knee-jerk reaction which occasionally borders on the nonsensical.

For example, its regulatory bulletin, Regulation of physical and chemical restraint, makes it clear that providing a safe environment for residents with severe dementia cannot override the residents’ “right to free movement”.

The directive explicitly states that residents need to be provided with the code to keypad secured doors, either by signage or verbally, so that the residents can leave at any time if they so desire. One wonders if anyone in the commission has considered the potential consequences of this directive – for residents, families, care providers, the facility or other innocent bystanders?

Have they taken note of the fact that rights always come with responsibilities? On face value one has to deduce definitely not.

Other equally farcical, and in many ways demeaning, directives include the obligation to document and report any patient receiving a psychotropic drug, any patient who has lost 3kg or more in a month and any patient who has had a fall.

What these directives fail to take into account is the context in which these events have occurred, and given the unique circumstances of each patient, what has been done (or should be done).

Importantly, just how much more unproductive extra work does all this recording and reporting create? How much does this additional bureaucratic burden increase the already low morale and disillusionment of staff?

And most frustratingly of all, how much more time does it take staff away from doing what really matters – spending time with residents?

Redesign is not achieved by doing more of the same thing. Redesign starts with a different way of thinking.

We need a vision of what a high quality, effective, efficient and equitable aged care system looks like.

Let’s hope the final report by the royal commission will force the Aged Care Quality and Safety Commission to release regulatory bulletins that make sense to the people having to do the care and enables them to do so with the compassion, empowerment and recognition their work demands and deserves.

Associate Professor Joachim Sturmberg is Conjoint Associate Professor of General Practice, University of Newcastle, Australia

References:

Royal Commission into Aged Care Quality and Safety. Interim Report: Neglect. Canberra: Commonwealth of Australia, 2019

Sturmberg JP. Health System Redesign. How to Make Health Care Person-Centered, Equitable, and Sustainable. Cham, Switzerland: Springer; 2018.

 Aged Care Quality and Safety Commission. Guidance and Resources for Providers to Support the Aged Care Quality Standards. Canberra: Commonwealth of Australia, 2019.

Annas GJ. Reframing the Debate on Health Care Reform by Replacing Our Metaphors. N Engl J Med. 1995;332(11):745-8.