‘A watershed moment’: sector reacts to royal commission report and four areas for immediate action

“Get cracking.”

That’s the overwhelming call from advocacy groups in response to the release of the aged care royal commission’s final report.

Council on the Ageing (COTA) Australia said the report’s release places the onus on the Morrison Government to address systemic issues with home care, nursing home regulation, staffing and transparency.

The group’s chief executive Ian Yates said: “The fact that there are a few alternative recommendations from the commissioners on the best way to manage and fund the aged care system in no way lets government off the hook. There are no barriers to commencing urgent and long-awaited reforms.”

In a statement, Yates said COTA would prioritise advocating for home care without a wait, a stronger regulator, a star rating system for staffing, transparency and consumer control and rights.

Overall, he said Prime Minister Scott Morrison should include in the Budget a major package with a clear timeline of when decisions will be made and implemented over the next four years.

Craig Gear, chief executive of the Older Persons Advocacy Network called the release of the report “a watershed moment”.

"The Royal Commission has confirmed that aged care must move from a substitute decision-maker model to a supported decision-maker model, which means preferencing the choices of the older person, and upholding their right to make these choices," Gear said.

An apology from providers

Within hours of the report’s release, a consortium of aged care provider peak bodies apologised for the harm endured by older Australians and their loved ones.

Speaking on behalf of the Australian Aged Care Collaboration, which represents organisations that provide 70 per cent of the nation’s aged care services, Sean Rooney said the report cited some appalling examples where individuals or aged care services had failed in their duties to provide safe and quality care for older Australians.

“These failures are unacceptable and we are sorry for the harm they have caused to older Australians and their loved ones,” said Rooney.

The Leading Age Services Australia chief added there have been too many examples of individuals and services who have failed people in their care.

“In recent times we have made changes to raise standards and we are continuing to do so. We are committed to doing better.”

Differing views ‘disappointing’

In handing down their report, commissioners Tony Pagone and Lynelle Briggs have set out a roadmap for reform in the aged care sector – but they couldn’t always agree on the best route.

Aged and Community Services Australia called the commissioners’ divergent recommendations “disappointing” but added that “there is no split on the need for a total overhaul”.

“This cannot be used as an excuse to not progress major reforms. We know what the big problems are – we now need the big solutions,” the peak’s chief executive Patricia Sparrow said.

"We need an overhaul, not just more top-ups, in order to guarantee respect for older Australians for future generations.”

Staffing

The final report recommended an appropriate skills mix and daily minimum staff time for registered nurses, enrolled nurses and personal care workers for each resident, and at least one registered nurse on site at all times.

The Australian Nursing and Midwifery Federation, which has long advocated for such changes, said the current government and many previous governments have done nothing to address ever-increasing shortages of registered nurses and qualified carers working in aged care.

The federal secretary of the union, Annie Butler, said: “The Morrison Government must now act; every day the Government delays taking action to address dangerous understaffing in nursing homes and community care is another sad day that vulnerable residents will continue to suffer.”

Aged care provider HammondCare, which assisted the royal commission through submissions, appearances and roundtables, said frontline aged care workers deserve to be paid on par with health and disability workers.

HammondCare chief executive Mike Baird added that the aged care sector as a whole must become more responsive to the consumer.

“We also support a star-rating system to shine a light on providers and help guide consumers as they decide on the appropriate level of care and services.”

Four concerns for immediate attention

In their report, Briggs and Pagone singled out four concerns for immediate attention: food and nutrition, dementia care, the use of restrictive practices, and palliative care.

Food and nutrition

The commissioners noted that many witnesses gave evidence about the inadequacy of the quality and quantity of food in residential care.

They pointed to a representative study of 60 Australian residential aged care services conducted in 2017 that concluded more than two thirds (68 per cent) of residents were malnourished or at risk of malnutrition.

“The current Aged Care Quality Standard for meals stipulates that ‘where meals are provided, they are varied and of suitable quantity and quality’. This leaves much to the discretion of the provider and is not easily enforceable. How ‘varied’ do meals have to be? What does ‘suitable’ mean?”

Briggs and Pagone said a critical first step would be to improve nutrition using funds gained through the elsewhere recommended immediate conditional increase in the Basic Daily Fee of $10 per resident per day.

Dietitians Australia said: “With a quarter of online submissions to the Commission referring to nutrition and malnourishment, we’re pleased to see food and nutrition, and support from a dietitian, given the priority it deserves.”

Dementia care

When it came to the second of the four areas for urgent action, dementia care, the commissioners offered this:

“Our inquiry has revealed that the quality of aged care that people living with dementia receive is, at times, abysmal.”

They said the commission heard time and time again that staff members do not have the time or the skills to deliver the care that is needed.

“All mainstream aged care services should have the capacity to deliver high quality aged care for most people living with dementia – dementia care should be core business," the report read. "This includes having the right number and mix of staff who are trained in dementia care, having the right physical environment (in residential care), and having the right model of care.

“We recommend mandatory dementia training in residential aged care and in care at home.”

The final report also recommended the establishment of a comprehensive and accessible post-diagnosis support pathway for people living with dementia and their carers and families.

Dementia Australia chief executive Maree McCabe said within the 148 recommendations were 14 key areas with a specific focus on dementia, including an assessment of the impact of dementia-specialist support and a review of aged care standards as they relate to quality dementia care.

McCabe echoed the words of people with the lived experience of dementia in saying, “if you get dementia care right you get it right for everyone”.

Restrictive practices

The final report called the overuse of restrictive practices in aged care a “major quality and safety issue”.

“Urgent reforms are necessary to protect older people from unnecessary, and potentially harmful, physical and chemical restraints,” it read. “A strong and effective regulatory framework to control the use of restrictive practices should be implemented as a matter of priority.”

It recommended that the government amend the Quality of Care Principles 2014 (Cth) to provide that the use of restrictive practices in aged care must be based on an assessment by an independent expert.

“It should be subject to ongoing monitoring and reporting, with a behaviour support plan lodged with the Quality Regulator,” the report read.

At a press conference on the release of the final report, Minister for Senior Australians and Aged Care Services Richard Colbeck said the government will further establish clear new obligations and guidelines around the use of restraint to protect older Australians receiving care.

“A Senior Restraint Practitioner will be appointed to the Commission to lead an education campaign for the sector and general practitioners, to minimise the use of restraint, and bring practice into line with those in the disability sector.”

Palliative care

The commissioners said a number of their recommendations will contribute to ensuring high quality palliative care becomes “core business” for aged care services.

“These include a right to fair, equitable and non-discriminatory access to palliative and end-of-life care, improved access to specialist palliative care services and requirements for regular staff training. Urgent consideration should also be given to how palliative care is reflected in the Aged Care Quality Standards.”

Palliative Care Australia chair Professor Meera Agar said: “Over a third of Australians will die in residential aged care, yet up until now, palliative care has never been considered core business in aged care.

"... we now have a very strong case to convince governments that we need to improve palliative care in aged care."

No excuses

In his preface to the report, commissioner chair Pagone quoted Uncle Brian Campbell, who said:

“I’ve sat with Royal Commissions into deaths in custody. I’ve sat with the Bringing Them Home hearing; right? And out of all of them hardly anything gets done, and is this one going to be the same?”

Pagone said the chairs’ disagreement about the best way for improvement to be achieved is not a justification for doing nothing.

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