Is aged care in Australia as bad as the media would have us believe?

There has been a lot of negative media regarding the standard of aged care services of late. And while some would appear warranted, it is always difficult as an aged care provider to be tarred with the soiled brush of another.

The latest SMH piece has targeted what they claim are inadequate staffing levels and cost minimisation practices (which result in substandard care) of a well known aged care provider.

The problem with this coverage is two fold:

1. What is Sub Standard Care?

"Sub standard or inadequate care" is a very subjective thing. It comes down to what a person will accept and what they are willing to do about it.

I remember visiting an aged care home under sanction a number of years ago and being abused by angry relatives because of government interference. Their perception (albeit probably clouded by guilt) was that the home was good and the criticisms being made were unfounded. The service was clearly broken and did eventually close.

I also remember visiting a home of a very well known 'not for profit' provider and saying to them the place was an absolute disgrace and needed to be closed only to be told by the CEO (as it was a service providing care to former homeless people) its better than sleeping on the street!

Because no one was complaining, the conclusion drawn was it was acceptable ... but pick up the service and put it in any other suburb of Sydney and the complaints would have been deafening.

I have operated aged care homes that provided care well beyond the norm, with high staffing levels, chef prepared meals, foxtel in every room and everything available that you would want ... only to fail to meet some people's expectations.

The SMH story uses the age old argument of continence aid provision as an indicator of quality care. A lot of the problem with continence aids comes from the marketing of companies trying to make sales (only 3 pads a day needed) but also comes from a lack of understanding of how incontinence aids work - they are not supposed to be changed as soon as they are wet (just like a babies nappy) and are designed to pull wetness away from the body. The other problem is cost - continence aids are extremely expensive (just think of baby nappies) and can easily cost an aged care service upwards of $50,000 a year ... making it a prime target for cost saving.

Many clinicians would agree that continence aids are poorly implemented in a number of services, and while they often are, they should not be used as a substitute for good old fashioned assisted toileting (which is exactly what they have become). This is compounded by a general lack of understanding across the general public about how they work.

The conundrum of staffing ratios is ever present and wont go away until the government has the intestinal fortitude to comprehensively cost the delivery of care and then match the funding to these real costs (or explain to the general public that what they want is not affordable).

But saying that, staffing ratios are a nonsense anyway. The number of staff required depends of a multitude of factors including but not limited to the needs of the residents, physical layout of the building, the technology available, the aptitude of staff, the expectation of relatives and residents ... and I have always said I can do more with ten great staff than one hundred bad ones.

Smart consumers should be comparing the homes average ACFI (which provides at least a basic comparative of care) against the hours of care staff provided per resident. The higher the ACFI (or resident acuity), the higher the average care hours provided should be. According to the figures I have available, the average ACFI for a typical home providing a high level of care is between $170 and $180 per resident per day.

The recent literature suggests that the average care hours provided in residential care is about 2.8 hour per resident per day. The unions and advocacy groups are calling for an increase to 4.3. So, it is reasonable to suggest that somewhere between 2.8 and 4.3 would be reasonable (but again depending on the level of resident acuity).

As a quick calculation:

• I have $175 per day to pay for care (staffing, medical supplies, food etc)
• I provide 4.3 hours of care staff so I am the champion of the union movement
• Even at the lowest rate of pay possible (ignoring the fact I need Registered Nurses) this would cost me $153 per resident per day
• If I follow the unions suggested split of staff (20% RN and 80% others) this would cost me more than $170 per resident per day (without a Director of Nursing or a Deputy Director of Nursing or a Clinical Care Coordinator)
• So I now have less than $5 per day to spend on food, medical supplies, continence aids, nutritional supplements, activities ....

I recently attended an open day for a new service where one participant asked directly about the levels of staff only to be told some cock and bull story about why they dont use ratios and cant specify how many staff they provide. All that was missing was the "we cant say because of privacy" and the story would have been complete. If I am going to fork out $1,000,000 plus to come into your home, the least you can do is answer my question and if you are not embarrassed about the number of staff you provide why not just tell people?

My advice - If you ask these basic questions and the provider does not answer ... then walk away and find someone who will.

2. The Fox in the Hen House

When you invite the fox into the hen house it is going to be ugly - for profits are there to make a profit, they dont hide the fact so it should not come as a surprise to anyone ... nor should anyone criticise them for it either. Its like inviting a vegan to dinner and then criticising them for not eating meat. If the government didn't want companies to make a profit, then they should not have approved for profit companies as approved providers of aged care.

Thats not to say the for profits are the only ones trying to make a buck. We all have to ... because without a profit / surplus we cannot expand, provide additional care, build new buildings, refurbish the buildings we have, or support community and social projects that the government does not.

Aged care is full of smoke and mirrors and a lot of "grey areas" on both sides of the equation and unfortunately it helps no one. The government has always refused to provide concrete direction in the fear they will get it wrong (which in their defense they probably would) and get blamed, and it is always easier to blame the big bad provider when things go wrong.

The Department of Health has used this tactic well for many years ... they outsourced accreditation so its the Quality Agency's fault, they outsourced complaints so its the Complaints Commissioners fault, they outsourced food safety so its the Food Authorities fault and everything else goes to My Aged Care because everyone blames them for everything anyway.

I have often used the analogy - we tell a person to get to a destination (in this case meet accreditation) but fail to tell them how to get there. When they dont travel the path we prefer we beat them with a big stick ... A major reason why I left the Department after being told to stop being helpful.

The whole aged care reform package is predicated on the fact that in a consumer driven market there is an expectation that people will vote with their feet ... unfortunately aged care simply does not work that way in many cases. Its not like a restaurant where you get a bad meal - you cant simply not go back when you are reliant on residential care.

The government knew this from the start and thats why the Aged Care Complaints Commissioner has a role - to provide the general public with some delusional ideation that they can complain and all will be fixed. Again, an idea not based in reality.

Everyone would benefit from clearer expectations, clearer direction and a clearer understanding of what it actually costs to deliver on what people want.

But at the end of the day, if I want to stay at the Intercontinental, I cant pay the price of an Ibis ... and like everything in life, it ultimately comes down to how much you (or the government) are willing to pay.

Its important to highlight the bad eggs and deal with them appropriately. Its equally important to embrace and acknowledge the wonderful job the majority do every day, often under less than optimal circumstances.