In Part 3 we looked at the workforce related issues, specifically how carers are struggling to provide appropriate care to our most vulnerable elderly population with highly complex needs. In this Part 4, I will address the systemic issues that largely structure and constrain the context of care delivery in residential aged care facilities, and look at some of the consequences of these constraints.
People tend to attribute blame to individuals, not systems. Even when it is clear that the system is to blame, they tend to blame an individual. They want to put a human face on the problem. For example, a former South Australian care worker was convicted of assaulting a 72 year old woman in an aged care facility, when he became frustrated with her behaviour of pulling out the buzzer cord. The magistrate Paul Foley sentenced him to 12 months’ jail with a non-parole period of nine months. https://www.abc.net.au/news/2019-04-15/former-adelaide-aged-care-worker-michael-andrew-mullen-jailed/11004376
In contrast to this, there has recently been authoritative recognition by the legal system that there are contributing systemic issues. As mentioned previously in part 3, counsel representing a convicted carer on appeal, Mr Ramage QC, successfully argued that the carer was a “victim of the system”. Mr Ramage QC told the court that “one of the great problems is lack of training and lack of staff”. The judge accepted the argument and the convicted carer was released from jail and served a revised sentence from home.https://www.msn.com/en-au/news/australia/jailed-aged-care-attacker-wins-appeal/ar-BBTSRnp?li=AA4RE4&;ocid=spartanntp&index=1
There are clearly existing systemic structures and constraints in the delivery of care (to address both physical and emotional needs).
Residential Aged Care Facilities have 2 primary sources of funding. Firstly they have “operational” funding which consists of the Federal Government funding together with contributions from individuals in care. Operational funding supports day-to-day services such as nursing and personal care, living expenses and accommodation expenses.
The Aged Care Funding Instrument (ACFI) is used to allocate government funds to service providers. The ACFI system has recently come under scrutiny as part of the Resource Utilisation and Classification Study (RUCS), according to a report released in March (Australian Health Services Research Institute, 2019). This resulted in a new assessment and funding model being proposed, known as the Australian National Aged Care Classification (AN-ACC) system.
Overall in 2017-18, the Commonwealth contributed 68.1% of total provider funding ($12.3 billion). Residents contributed 26.6% ($4.8 billion); and income from other sources comprised the remaining 5.3% (Aged Care Financing Authority, 2019).
From my research and reading, there is no transparency or accountability regarding how the Government funding is spent by RACFs to provide quality care. The Federal Government seeks to “regulate” this system through the accreditation process, and has recently released new Aged Care Quality Standards (Australian Government, 2019).
Secondly, RACFs are funded by “capital” financing. Capital funds consist of the Resident Accommodation Deposits (RADs) and any borrowings by the RACF. These funds support the construction of new RACFs and the refurbishment of existing facilities. These funds cannot be used for operational costs ie. clinical care or services for individuals. The pool of lump sum Resident Accommodation Deposits grew from $15.6 billion in June 2014 to $27.5 billion in June 2018, an increase 76.3% in 4 years (or 19% per year on average)!
The Business Model
A primary systemic constraint on the Aged Care system is that RACFs are struggling to provide quality care within their “operational” budget. To come in on budget, and/or to make any profit, service providers seek to minimise costs. Elements that are highly susceptible to cost cutting include:- i. staffing (quality and quantity), resulting in the loss of opportunities for the development of relationships with residents; and
ii. food (quality and quantity).
Thus, we have heard stories recently from the Royal Commission of facilities spending $6-7 per person per day on food, and setting limits on the number of incontinence pads that are to be used per day eg. in some instances, 3 per day. Lack of funding for training staff is also an issue.
Consequences of financial constraints
Best practice has been identified as being “person-centred” and “relationship-based” models of care (addressing both physical and emotional wellbeing). However, it is questionable as to what proportion of facilities are able to provide this and what proportion remain “task focused”.
The task-focused approach could be described as “Taylorism” as applied to humans. The definition of Taylorism is:-
“…..a methodology that breaks every action, job, or task into small and simple segments which can be easily analysed and taught. Taylorism (1) aims to achieve maximum job fragmentation to minimize skill requirements and job learning time”. http://www.businessdictionary.com/definition/Taylorism.html
This is a system of work structuring which reduces human agency and autonomy of workers.
Typically, in residential aged care facilities, the carers’ time is structured around physical tasks to be completed, leaving little or no time for building relationships between carers and residents. The psychosocial elements of care are not prioritised in this model. As 84 year old Merle Mitchell stated “The staff don’t have time to talk to residents because they’re under so much pressure to be able to fulfil their requirements” (Aged Care Royal Commission, 2019).
Currently there is no mandated staff to resident ratios in residential aged care facilities. This means that care staff often struggle to care for the residents that are assigned to them each shift. If an individual resident requires 2 staff for personal care, then one staff member must be taken from their allocated residents to help the other.
The Royal Commission into Aged Care Quality and Safety is underway, and has been receiving submissions related to some or all of these issues. What I am proposing to recommend in the Amazing Ageing Psychology submission to the Royal Commission includes:-
- Staffing in RACFs
i. Mandated minimum staff to resident ratios, based on research evidence.
ii. An increase in the proportion and numbers of registered nurses to personal care workers in RACFs.
iii. A recognition that personal care workers are not nurses, and have minimal education and training.
iv. Recruitment processes to include assessment of personality, motivation and commitment.
v. Mandated minimal qualifications for personal care workers, including standards of English language, both spoken and written.
vi. Access to appropriately trained and qualified allied health services.
- Education and Training
i. Specialised mandatory education and training in mental health, dementia, and managing challenging/response behaviours, delivered by experienced clinicians in the field, for all staff in RACFs including managerial staff.
- Access to Psychological Assessment and Treatment Services
i. Immediate increased access to psychological assessment and treatment services for people living in RACFs. This is (supposedly) being addressed by Federal Government funding of the Primary Health Networks. A review of this model ie. commissioning through Primary Health Networks, is also recommended.
- Funding model of RACFs
i. Link the new funding system to staffing ie higher scores means more staff hours for that person ie. a dependency model.
ii. Far greater regulation, transparency, and accountability around how tax payer’s money is being spent.
iii. Ensure that the general public are aware that their RAD is not used for the provision of their care.
iv. An investigation into the systemic factors that constrain and prevent the delivery of high quality care.
When we hear about and see abuse and neglect of our older people in care, we are rightly outraged. In response, we need to consider and address the underlying causal factors including the multitude of clinical issues, the workforce related issues, and the systemic issues constraining the delivery of quality care. Amazing Ageing Psychology hopes that this series of blogs over the past year has highlighted the complexity of these underlying causal factors, and we look forward to the Royal Commission’s interim and final reports.
Senior Clinical Psychologist
BA (Hons) MClinPsych MAPS (Clin. College)
Amazing Ageing Psychology
ABC. (2018). “Who Cares”? – Four Corners – ABC
Aged Care Financing Authority (2019). Annual Report on the Funding and Financing of the Aged Care Industry-2019.
Australian Government (2019). Aged Care Quality Standards. https://agedcare.health.gov.au/quality/aged-care-quality-standards
Australian Health Services Research Institute (2019). The Australian National Aged Care Classification (AN-ACC). The Resource Utilisation and Classification Study: Report 1
Business Dictionary. http://www.businessdictionary.com/definition/Taylorism.html
Royal Commission into Aged Care Quality and Safety (2019). Transcript, Sydney. May 6th, page 47. https://agedcare.royalcommission.gov.au/hearings/Pages/Transcripts.aspx.
Livingstone, T. (2019). Jailed aged care attacker wins appeal. https://www.msn.com/en-au/news/australia/jailed-aged-care-attacker-wins-appeal/ar-BBTSRnp?li=AA4RE4&;ocid=spartanntp&index=1
Opie, R. (2019). Former SA aged care worker jailed for elder abuse as victim’s family label him a ‘monster’.