In the last week of February the Royal Commission into Aged Care Quality and Safety will issue its final report. When that document is made public, will the recommendations create an agenda for aged care over the next decade or will they gather dust like some other reviews of this sector?
Already we have some idea what to expect. The interim report was released in October 2019, and this past October the Counsel Assisting put forward 124 recommendations for the consideration of the Royal Commissioners.
To get some expert opinion on what comes next, we interviewed leaders in aged care. We spoke to people working in aged care provision, in government regulation and in sectoral advocacy. We were keen to know what impact they thought the proposed recommendations would have, which would make the biggest difference and what else they wanted to see in the final report.
Because of the sensitivity of the issues involved we agreed to protect their identity, but the insights they offer are valuable for anyone keen to understand how aged care can seize this historic opportunity.
The Royal Commission has created a shared impetus for change
The public hearings, roundtable discussions with experts, community forums and reports have uncovered serious failings in aged care that have attracted public criticism and in some cases condemnation. These discoveries have been the impetus for the government, providers and the public to call for urgent action to overhaul of the sector.
The government and providers are poised and ready to implement the Commissioners’ overhaul of aged care. Providers have all publicly committed to improving aged care, and coupled with increased scrutiny and heightened public awareness, they have been put on notice that if something goes wrong it will need to be acted on rapidly. This should reduce the instances of sub-standard care.
The Royal Commission has highlighted that the aged care sector is significantly underfunded, with funding insecure and subject to the changing fiscal priorities of government. Without sufficient funding, providers cannot offer high-quality and safe care. Insufficient funding impacts most aspects of care, including the size and skill mix of the workforce, quality of physical environments, access to technology and effective linkages between systems.
There is now an acknowledgement that the aged case sector is structurally underfunded and is going to require more funding.
We have a once-in-a-lifetime opportunity for reform
The leaders we spoke to overwhelmingly support the thrust of the 124 recommendations proposed by the Counsel Assisting. Sifting through the recommendations, they have identified five that would make the greatest difference to the quality of care received by older Australians.
- An Aged Care Act focused on human rights. A new Aged Care Act based on human rights principles that emphasises that older people have the right to a meaningful life attracted strong support. The Counsel Assisting has called for a rights-based governance system, led by redrafting the Aged Care Act. Such an approach is consistent with the philosophy of person-centred care and will support the delivery of quality and safe care to residents.
- A sustainable workforce that is skilled, resourced, well remunerated and responsive to consumers’ needs. There is consensus on the importance of a workforce to meet the needs of older people. The Counsel Assisting has called on the Aged Care Workforce Planning Division of the Department of Health and the Aged Care Workforce Industry Council to lead the sector in designing and planning workforce strategies, reviewing competencies and developing a workforce structure with clear career pathways. A focus on deliberately developing and fostering a sustainable workforce, with emphasis on staff capabilities in dementia care, mental health, culturally-specific care, and end-of-life care, would facilitate a variety of service offerings, at different levels of care, while maintaining high standards and minimising risk.
- Timely access to care that meets preference to age in place. There is a strong case for making home care packages available according to need. Immediately increasing the availability of home care packages, and by the end of 2021 allocating a package to everyone on the waiting list who does not have a package at the level they have been approved, would be life-changing for older Australians who have spent up to 12 months on a waitlist.
- Establish a dementia support pathway and specialist dementia care services. Enabling people living with dementia, their carers and families to receive the support and care they need has been described as a recommendation that will make the biggest impact on the quality of care. The proposal is for establishing a comprehensive, clear and accessible post-diagnosis support pathway for people living with dementia and their carers and families. It also involves building capacity and capability in dementia care in the aged care workforce and reviewing and setting appropriate standards for the physical design of facilities in which people living with dementia live and receive care.
- Graded assessments of service performance and performance ratings increase transparency. Increasing transparency of service attributes and performance has strong support. Graded assessments of service performance against Aged Care Quality Standards combined with developing and publishing star ratings for service quality and safety, staffing levels and consumer experience would make providers more accountable and increase consumer confidence in care. Obtaining a more sophisticated understanding of how providers perform will empower consumers. Transparency in communication, reporting and accountability of services would be critical in improving aged care quality.
But these are all contingent on ‘ifs’
The aged care leaders are confident that those five areas would have the greatest whole-of-system impact on the quality of outcomes for older Australians. But their confidence is subject to some contingencies:
- Adequate funding to finance implementation. Aged care funding is constrained and the system is under additional strain due to the resources required to respond to COVID-19. So there is concern whether required funding will be provided and whether the sources of that funding will be identified and secured. As one leader explained, “I’m not as confident the Royal Commission will change quality of care. I am concerned the reforms will be diluted because the government will address low cost/low impact recommendations (60 per cent) without really investing to address higher impact opportunities (40 per cent).”
- An implementation plan that prioritises recommendations. Among the 124 proposed recommendations was the establishment of an implementation unit within government. Aged care leaders argued for the Royal Commission to prioritise and sequence the recommendations, to define the governance for the changes and identify who will drive them.
- Make the sector more inclusive, including targeting disadvantaged groups. Aged care leaders said it was important the final report included actions aimed at supporting disadvantaged groups, without which there could be an undersupply and lack of diversity of services. Relevant groups include Aboriginal and Torres Strait Islanders; culturally and linguistically diverse people; regional, rural and remote communities; LGBTI people; and people at risk of homelessness. Examples of actions include more bespoke services to meet the needs of different groups and detailing the interface between health and aged care in these communities. As one leader said, “We need a revolution not an evolution.”
- Address chronic ageism, which limits change. Most Royal Commissions in Australia take two to three terms of government to implement all recommendations. To deliver on the recommendations in the proposed five years, the final report needs to describe clear steps to engender the cultural change required in aged care organisations, governments and the public that addresses the ageist mindset that undervalues older people and limits their possibilities. Everyone has a role to develop a sustainable aged care system that delivers uniformly safe and quality care for older people: the public needs to demand high-quality services and advocate for change, the government needs to finance and regulate the services, and the aged care sector needs to implement the transformation required.
A few things are missing from the proposed recommendations
The Aged Care leaders we interviewed identified three additional areas that the final report ought to include:
- Establish meaningful consequences if people fail to meet targets. The Royal Commission’s interim report said that many deficiencies in aged care were known to the providers concerned and to the regulators before becoming public, yet little had been done to address them. The final report should not only detail how the system will be governed but also describe the consequences of non-compliance beyond the potential application of a civil penalty by a Court. These consequences should be commonly understood and consistently implemented.
- Create the system of tomorrow instead of only improving the system we have today. The aged care leaders said Counsel Assisting’s recommendations focused on regulating the sector as it is today and not on how it will look tomorrow. This means the recommendations seek to address shortcomings in today’s residential aged care sector rather than treating home and community as the primary locus of future long-term care. While the issues in residential aged care need to be addressed, questions that ought to be considered are: What are benchmark examples of integrated accommodation and care models and how can these be enabled? What other funding models enable a sustainable, community-based aged care sector? Are there better forms of respite and associated funding models? How does the sector shift its workforce focus from what we have now to building the workforce for the future?
- Achieve shared ownership from national and state/territory governments. The Aged Care leaders noted that the pandemic has demonstrated that an effective health system depends on an effective aged care system. There needs to be formal recognition that the systems are interdependent and that the national, state and territory governments all have a role in enhancing the health and aged care interface.
We are on the precipice of a great opportunity
The Royal Commission presents a unique opportunity to reset the sector. The participants are ready and aware of the pressing need to change. There is a sense of expectancy and urgency. As one leader told us, “There is a preparedness and willingness to actually do something.”
How we take advantage of this opportunity will depend on prioritising the areas of change that will make a difference and satisfying the “ifs” – the provisos that will facilitate the successful implementation of the key recommendations. If that can occur, the lives and care of older Australians will be improved dramatically.
Get in touch to discuss how we can help you design and implement the future of aged care.
Thanks to the aged care leaders who took part in our interviews.
Connect with Stephen Teulan and Nikita Weickhardt on LinkedIn.
A shorter version of this article was first published on Australian Ageing Agenda on 20 January 2021.
 Interim Report, Royal Commission into Aged Care Quality and Safety
 Counsel Assisting’s Proposed Recommendations at Final Hearing, Royal Commission into Aged Care Quality and Safety
 ”A Shocking Tale of Neglect”, Extract from Interim Report, Royal Commission into Aged Care Quality and Safety
 Counsel Assisting’s Final Submissions, Royal Commission into Aged Care Quality and Safety
 “COVID-19 in aged care: A human rights approach”, MinterEllison