Caring (for the bottom line) in residential aged care
October 20th, 2017 | Published in Favorites, Later life
It makes bloodcurdling reading, the series of articles by Fairfax Media on residential aged care in Australia (click here, here, here, and here).
“Over the years, residents in nursing homes have been raped, robbed, bathed in 
kerosene, attacked by rodents, suffered injuries or death from other residents, burned to death, strangled, cooked, melted, sedated to death, over-medicated, endured horrific infected pressure sores, or choked to death,” notes Lynda Saltarelli, community advocate.
This is an alarming list, although Pat Sparrow, CEO of Aged and Community Services Australia (ACSA), a lobby group for the not-for-profit facilities, suggests the articles showcase a few bad apples.
“Media coverage has cast aged care in a negative light, based on individual experiences of care,” she says.
Another industry lobby group, Leading Age Services Australia, also reduces the problem to a few bad apples.
I don’t think so. The fault lines are systemic, as the articles demonstrate.
The case studies included in the articles represent symptoms of a broader malaise (Dawn Weston who died of gangrenous pressure sores; Maria Costa whose untreated urinary tract infection lead to fatal consequences; Jyl, whose son was inundated by calls spruiking for business; and John Daly whose wife complained, without satisfaction, of the excessive restraint in his ‘care’).
Confining the problem to ‘a few bad apples’ is exactly how the institutional abuse of children was enabled to continue for decades, sheltered from the rigorous investigation more recently provided by the royal commission. Now, at the other end of life, there are lessons to be drawn from that history.
The reality is that residential aged care is big business, profits take precedence over care, the accreditation system eclipses neglect and abuses, the complaints process is ineffectual, and the market myth camouflages the cracks.
This post expands these points, drawing on the series of articles.
Residential aged care is big business
There are many people and much money involved in aged care.
More than 195,000 people currently live in residential facilities. By 2050, this number is expected to be more than five million.
Daily fees are a function of the resident’s assets, and might be around $200. This amount is augmented by the federal government subsidy so that the total amount available for care is around $350 per person per day.
This may seem a lot of money for care (it doesn’t include charges for accommodation, and it’s not all spent on care, as subsequently noted). It is, however, much less than the cost of keeping someone in hospital at $1000 to $1500 per day. The pressure is therefore high to move elderly people from hospital to residential care if they are unable to go home. Families might have just a week’s warning to secure a place.
The sector as a whole (private and not-for-profit) cleared $1.1 billion in 2016. Top tier private companies and some of the big not-for profits make up to $25,000 per bed per year, a figure that grows every year. Such excesses are essential, according to Pat Sparrow, for reinvestment in infrastructure that will be required as baby boomers age.
Maybe. Although keeping shareholders happy is perhaps an even more compelling imperative.
Profits take precedence over care
Nursing homes have been encouraged to make profits ever since John Howard, as Prime Minister, passed the Aged Care Act in 1997.
Substantial profits derive from the government subsidy, which comes in the form of ACFI (Aged Care Funding Instrument). This works by paying more as residents get sicker. The ACFI payment does not, however, have to be spent on care. It can be used for anything, including executive salaries and dividends for shareholders.
Financially high performing homes spend only two-thirds of their ACFI funding on care. Providers hire consultants to maximise their take, keeping ACFI up and costs down.
Profits and surpluses are also achieved through cutting costs on staff and food.
There is no minimum legal ratio of staff to residents, no minimum training requirements, and no statutory requirement to have a nurse on duty at all times.
Pay rates are low at $18 to $19 per hour for inexperienced workers. “You can earn more at Aldi,” says Bev Myers, aged-care trainer and former nurse.
Food is another source of cost-cutting. The budget for food, even at the ‘good’ places is skimpy, ranging from around $4.50 on average to $11.00 per person per day at the top end.
A recent study by dietician, Dr Skye Marshall, found half of all residents in aged care are malnourished. This does not seem surprising.
ACFI is in fact silent about “the adequacy of meals and the quality of food“.
Accreditation eclipses neglect and abuses
Politicians and providers claim that Australia’s standard of care is world class. The basis of this assertion is the accreditation system.
Every three to five years The Aged Care Quality Agency audits a facility and measures it against 44 expected outcomes. Facilities are given several months’ notice and the big providers have accreditation teams that sweep in to make sure all is well prepared.
Facilities achieving 44/44 include those that housed Dawn Weston (a few months after 
she died of gangrenous pressure sores) and John Daly (who died of sepsis and who, according to his wife’s formal complaints, was restrained excessively).
Figures from the Department of Health show that 26% to 42% of residents in Australian aged care facilities have pressure sores. In the US it’s 6.2%. This comparison provides poor grounds for claiming world class care, and it’s the only comparative data that seems to be publicly available.
Complaints process is ineffectual
The vast majority of complaints about residential facilities are about the standard of care – not enough carers, lack of adequate training, lack of experience, and difficulties of communication.
Reports on complaints to the Aged Care Complaints Commissioner are not made public and legislation prevents naming and shaming. Many are referred back to the provider to deal with in-house.
So, for example, when Gabrielle Costa complained to the Commissioner about the care of her grandmother (who died from complications following an untreated urinary tract infection) the complaint was passed back to the agency. The site was monitored, passed, and no further action was required.
The incidence of preventable deaths, such as Maria Costa’s, is growing, according to Professor Joe Ibrahim, who studies coroners’ reports to identify such instances. His work, unsurprisingly, does not attract a lot of funding.
Ken Wyatt, Minister for Aged Care, acknowledges the complaints system lacks teeth. In the US, for example, complaints and negative findings are published online. In Australia, consumers rely on industry advertising and bureaucratic reporting.
By contrast to the complaints process for residents and their families, providers have a powerful collection of lobby groups protecting their interests. These include:
- Aged and Community Services Australia (ACSA);
- The Aged Care Guild;
- Leading Age Services Australia (which has warned that any changes to the complaints process should give nursing homes a right of reply).
“The government and industry own the system,” says Linda Saltarelli. “The families don’t. So, when there’s a complaint, it’s families versus nursing homes and government.”
Pay up and shut up is the message beyond the marble foyers and sparkling chandeliers.
Market myth camouflages the cracks
The balance of power clearly lies with service providers, but the way forward, apparently, is to let the market do its work. Put consumers in charge, and keep a light hand on regulation.
Consumers, in this case, might be residents or their families.
But, the problem with rhetoric about control in the hands of residents is that many, possibly most, are not in a position to advocate for themselves.
Approximately half of all residents have dementia. Many cannot move, speak, or toilet themselves. Eighty percent require high care. One-third die each year. Half are malnourished.
“If you’re eighty or ninety, and in residential care, and have dementia, your ability to formulate an argument and stand your ground isn’t there any longer,” says Professor Ibrahim. Being totally dependent on hired hands for your most intimate needs does not encourage assertiveness.
And, if residents did become assertive, I expect they would be quickly put in their place, and chemically restrained if necessary – to avoid them being ‘difficult’ or ‘too distressed’.
The increasing choice and control older Australians are said to have in relation to aged care are fictions, I would argue, of the neoliberal mindset.
As for the families of residents, they’re the ones who supposedly find the ‘right’ home and act as advocates for their aged relatives. But, committed as they might be, they run up against implacable barriers.
Outside the Victorian government system, there is no published information on pressure sores, medication errors, weight loss, falls, infection rates, admissions to hospital, or anything about dignity, privacy, freedom to make decisions, or freedom to choose leisure activities.
Family members find it impossible to get basic information like staff resident ratios (the facilities are not required to provide them) and their complaints are not taken seriously.
According to Maria Bohan, former CEO of Carers Victoria, “many families do not have the confidence to act as advocates”. Maybe not, and maybe it would make a difference, but the system would also need to be more transparent, responsive, and simpler to navigate. Most people do not have the advantage of Bohan’s seventeen years of employment in the sector.
Advocates of deregulation argue that a deregulated system would fix problems with care 
because consumers would only want to live in homes that provide a top-quality service. These homes would supposedly thrive at the expense of others.
More providers facing fewer regulations would, the story goes, create diversity, choice, competition, innovation, and responsiveness.
Just as was supposed to happen in the vocational education system – and didn’t. Rather, the rorts, scams and rip-offs are still unfolding.
The ‘light hand of regulation’ has served us poorly in other areas, and is unlikely to yield better results in aged care. Already, in terms of staff numbers and basics such as food, the effects are not encouraging.
Aged care needs more care
The editorial comment accompanying the series of articles sums up the situation as follows:
- Most aged care is provided by private firms, which charge such large deposits that many people have to sell their home to finance a place. The sector also receives billions of dollars of direct funding from government.
- The profit margins and investment returns of these businesses are far higher than average, suggesting clients are being gouged, not only through inadequate staffing and care, but through inadequate spending on food.
- The accreditation and accountability processes are essentially useless. Facilities in which serious harm has occurred manage to score spotless bills of health from the regulator. The industry’s claims that it provides world-class service and care, and that cases of neglect and harm are anomalies, lack credibility.
The market mantra might camouflage the cracks from the outside, but as one registered nurse put it who has worked in nursing homes for 10 years “I do not want to become a resident, ever, of any aged-care facility I have worked in”.
We need to take heed. We all get old – if we are lucky (or, perhaps, unlucky, given current trends). Somehow, we need to find the way to bring about change.
Aged care (along with many other areas) needs more care for people, and less care for the bottom line.
NOTE: If you like this post, you might also be interested in
Aged care cuts: My old friend is scared and needs solidarity
in the category of posts on Later life
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Joan
I came home from Mum’s aged care facility today and cried, like I do on many days each week.
Not sure if it’s feeling guilty that we placed her in care, or if it’s frustration over the Administrative people who keep cutting costs but don’t increase care…
They say they are “One of the best’ but I now think they are just not one of the worst…
I don’t blame RN’s or Carers, they too are victims of a horrible system.
Perhaps the CEO’s of both not for profits and profit making facilities need to be a resident for a day and night (disguised of course) to see what really happens.
Thankyou all for comments, I wish you and your families some peace and joy in the days ahead.
I think the process of witnessing inadequate care would be excruciating, and I imagine there are many tears shed. I agree, the change we need is systemic rather than at the level of staff. Your idea of giving CEOs some direct experience would be an interesting possibility. But, then, my cynical brain suggests that CEOs who developed too much empathy might be quickly replaced by others more focused on the almighty bottom line!
Research report by Dr Sarah Russell (October 2017) “Living well in an aged care home”, based on material provided by 174 relatives and visitors http://www.agedcarematters.net.au/wp-content/uploads/2017/10/LivingWellAgedCareHome.pdf
I work in aged care and take great pride in the care we provide. We take the time to understand the person so we can relate to the behaviours they may be exhibiting. We walk beside them in their journey and love them as family. The funding model is crap but good care is still possible with in it. I am proud to provide excellent care to our residents.
Wendy, deep thanks to you, and all the others like you. Those you care for are clearly well cared for and treated as human beings. If all was well at every level of the system, that “walking beside” kind of care would be what the majority of residents could expect.
When I visit the facility a friend has been in for many years (which I can’t fault, by the way, and where the climate set from the top down is warm and attentive) I often look at the other residents and wonder “Who are you?” Every one of them would have interesting stories about their lives. I guess you would have heard many.
I hope you continue to work in aged care for a very long time.
I work on and off several times in aged care – last place mainly nights and evening shift nights 2 of us 36 residents no Rn other than on call via phone which was often not answered, nights mostly times sole worker again RN at the end of a phone, just before I left they did bring in an early morning shift 1 extra worker that arrived from memory about 3am – that was for my meal break uninterrupted think she worked thru to 8am. I have to smile at the sections talking about choice of nursing home as it is usually take what you can get – we are rural and many people can not get accommodation where the family are let alone have a choice
Thanks for your coments, Suzie. What you say about staffing levels is particularly interesting because it’s information facilities don’t have to provide. Your figures make it clear why they might be reluctant to disclose.
Also, your point about ‘choice’ is important. That kind of market-speak is pretty farcical generally in relation to the aged care context, but in regional, rural, and remote areas it becomes even more problematic. What would the marketeers say? ‘Customers’ have the ‘choice’ to relocate to city areas where more and better facilities are available? I don’t think so. Not if it means visits from family become a rare occurrence because the commute is prohibitive.
Great article, well written. I think I’d rather die homeless on the street than end up in aged care.
The really disturbing part of that is that I know you, and others who say likewise, are not speaking lightly.
Joan reading your documentation made me feel great sadness, I felt like I was reading my many letters back to myself. I wud love to b able to speak with u at some stage
Helen, I am so sorry this has made you sad. It sounds like it is very close to home. I will use the email you have provided and send you my mobile number.
I wonder if you are also aware of the Aged Care Matters project (website and Facebook group; see my reply to Nia’s comment that inculdes the links)? That group would definitely have more knowledge and experience between them than I have. I don’t have any claim to authority on the system, really, just a deep concern and a deep recognition that all is not well and will no doubt get worse unless the community mobilises.
Sarah Russell is doing quite a bit behind the scenes and runs a Facebook page AGED CARE MATTERS.
I have carers come to me who have left the Nursing homes due to the bullying and mistreatment of residents.
Many thanks for this useful information. I have applied to become a member of the Facebook group (https://www.facebook.com/groups/366562520398847/) and have also had a preliminary peruse of the associated website (http://www.agedcarematters.net.au/) which covers so many areas that seem crucial. I’m sure this information about Sarah Russell’s work will also be of interest to others who comment on my post.
A couple of links I came across that may have some relevance to understanding the existing system (as distinct from groups promoting sea change, which I was unable to find. This may be a comment on my search skills, or it may be a reflection of the level of activist activity.)
Aged Care 101 https://www.agedcare101.com.au/
Aged care guide https://www.agedcareguide.com.au/talking-aged-care/public-forum-discussing-quality-in-aged-care
Thanks Joan, I think your work here is a fantastic start. The only way we will see change is through mobilising the communities outrage. When that voice becomes loud enough, the politicians will have to address it, or risk losing their seats in the parliament.
Most advocates working in this area do not have the profession approach required, and quickly become labeled troublemakers by industry and government.
That is why I started following your work, as you understand the required approach to be taken seriously, and you are highly qualified in your field.
A network of professionals dedicated to social justice might be able to push this issue forward, similar to what we have seen with euthanasia in Victoria. However it is likely to be a long road as the community is apathetic. I would certainly be happy to be involved – this is an issue that is important to me personally as well as professionally.
It’s crucial to find ways of intervening that are constructive and not counterproductive. But, that’s a big ask when up against a powerful industry, especially one that’s consistent with the zeitgeist of the (neoliberal) times.
Just a group of committed people brainstorming ideas would be a start.
Stay tuned for any brilliant possibilities from other commenters!
(And, thanks for the positive feedback. I appreciate it, although also chafe at wishing to be able to do more.)
P.S. Evan, you might be interested (or perhaps already know) of the work being done by Dr Sarah Russell. I have been told about it by Nia (see her comment) and my response to her includes links to the relevant website and Facebook group in case they are of interest.
My nursing career began in aged care (20 years ago). I was encouraged to leave Aged care as it was considered a place to end your career, not begin it. I worked in a variety of other clinical areas before I ended working for the Department of Health and Ageing.
When my grandmother died in a nursing home she was a frail shadow of the woman I grew up with. The coroner found that she died of drug toxicity – she had enough antidepressants in her tiny body to kill a large animal like a horse. The nursing home suggested she must have been self medicating, until I pointed out that she was physically incapable and that they were responsible for the safe administration of her medications. Then I was labeled the trouble-making grandson.
I then began working in the Aged Care Complaints Scheme investigating complaints about Aged Care. Legally I can not disclose information about my experiences in the scheme – however I note that I was busy for many years dealing with complaints like those described in this article.
I joined the scheme because I wanted to make a difference in the lives of elderly people like my grandmother that need care. I left in disgust – the system is in disarray. The industry and the government are in a race to the bottom, and it is the elderly that suffer the consequences of these failures.
I talk to everyone I know who will listen about the state of the industry – the government will not take action until we, the community, show them that the current system is unacceptable and we demand better care for the elderly.
We often credit this generation with building the Australia we know and love today – how can we allow them to suffer this injustice?
Thanks for your comments, Evan, which provide a valuable insider-outsider dual perspective. There’s a comment I’ve quoted from Lynda Saltarelli, community advocate, that comes to mind in relation to your insights:
“The government and industry own the system. The families don’t. So, when there’s a complaint, it’s families versus nursing homes and government.”
Do you have ideas about how to proceed in mobilising community action? Some way ahead that might transcend the power of the industry and its lobby groups?
That is such infuriating cr*p you were given, by the way, about your grandmother self-medicating, but sounds way too par for the course for comfort.
As many aging friends have noted, living longer opens a whole new spectrum of quality-of-life issues. A good friend’s wife developed Alzheimers in her sixties. After a few years, when she was admitted to a “care” facility, she became a problem for the skeletal evening staff because she liked to walk and would often leave in the wee hours. The nursing home demanded she be moved to a secure facility. She hated it and even in her reduced mental capacity became lucid enough occasionally, to tell them so.
Thus ended any quality of life for her. She spent two miserable years locked up before she passed, from what I’m convinced was a broken heart. Certainly a broken will to live.
I dread the day I am committed to such a system.
That is such a sad story, doryman, but one I fear might be all too common. And, the thing I would most like recognised is that it could be any of us. When I imagine the life of your friend, something in the region of my own heart dies a little.