The evolution of Australia’s aged care system towards a consumer-driven, market-based model was highlighted by a number of inquiry participants. The current aged care market has an under supply of residential aged care places, particularly for those with dementia, which restricts choice for consumers and innovation for aged care providers.
Australia’s ageing population presents challenges to the aged care system as it currently operates. By 2056, older Australians will make up 22 per cent of the population, an increase from today’s figure of 15 per cent. This will lead to significant pressure on the aged care system, particularly as dementia rates also increase to more than one million dementia sufferers by 2056, which is more than double today’s figures.
Although the aged care system is evolving, careful planning will need to be undertaken to ensure that the quality and type of care delivered matches the expectations of current and future residential aged care consumers.
Changing Expectations, Changing Culture
Australia’s ageing population will see a larger percentage of Australians over the age of 65 by 2056, but it will also lead to a changing age profile. The Australian Institute of Health and Welfare (AIHW) projects the proportion of Australians between the ages of 65 to 74 years to decrease from representing 57 per cent of Australia’s older people to representing 45 per cent in 2046. The next age bracket, between 74 to 84 years is set to increase from 30 per cent to 35 per cent, and the 85 years and over age bracket will increase from 13 per cent to 19 per cent in the same time period.
The Australian Medical Association (AMA) stated that the aged care system currently ‘does not have the capacity, capability or systems integration to adequately deal with this growing, ageing population’. The Queensland Nurses and Midwives’ Union (QNMU) similarly stated that there may not be enough Registered and Enrolled Nurses (RNs, ENs) to be able to meet minimum targets for nursing staff in residential aged care. The QNMU stated that the targets could not be met today, but the workforce could be grown to reverse the ‘long-term decline’ in the number of RNs and ENs.
The Department of Health stated that it is currently examining the longer term needs of the aged care workforce:
There is a view that the aged-care workforce will grow to almost one million people over the next decade. It will become a really significant part of the economy. So we need to make sure we get the right kind of people who are skilled in the right way and paid in the right kind of framework.
The Department of Health’s Aged Care Workforce Strategy Taskforce (Taskforce) has been established to develop a ‘strategy for growing and sustaining the workforce providing aged care services and support for older people, [and] to meet their care needs in a variety of settings’. The Taskforce has focussed on five strategic imperatives for the future of the aged care workforce:
Recognising consumer demand, and ‘acknowledging it is essential to have people that want to belong to this industry’;
Industry leadership, mindset and accountability;
Transitioning the industry operating model to a future state;
Industry attraction and retention; and
Using research and technology for new models of care and practice.
Next Generation of Aged Care Consumers
Aged care providers, advocates and family members of aged care residents described the changing demographics of aged care consumers as the Australian population ages and the generation of ‘baby boomers’ begins to enter residential aged care.
The ‘changing face’ of aged care users was put forward by the Older Persons Advocacy Network (OPAN). The OPAN stated that the current generation of aged care consumers have a different set of expectations to the next generation:
When I started in my current role, about four years ago, and talked to the advocates who have been working for many years about the current users of aged care they described them as, 'The grateful generation'. They are a cohort of people who are grateful for what they get, they're reluctant to complain and they accept things that others wouldn't necessarily.
Mrs Yvonne Buters similarly stated that the current generation of aged care residents are ‘a generation who have typically not complained, especially to authority figures and government’.
The OPAN stated that the effects of the changing face of aged care consumers had started to be seen in home care based services, and that ‘residential aged care absolutely needs reform’. The New South Wales Nurses and Midwives’ Association (NSW NMA) also stated that the standard of care currently being delivered ‘won't meet the expectations of [the next] generation when we face it’.
Estia Health agreed that the next generation of residential aged care users will have different expectations around quality of care:
Contemporary consumers and our interactions with the next generation of aged care residents provide strong indicators that there is an expectation of more than the baseline Government requirements reflected in the legislation.
The Aged Care Industry Association stated that more funding for residential aged care would be needed to meet the needs of older Australians in the future, and stated that: ‘If you put today's consumers in a 1950s hospital, I think you'd have an awful lot of complaints going on. As our expectations and our requirements expand, they do get more expensive’.
The Federation of Ethnic Communities’ Councils of Australia (FECCA) drew attention to the increasing numbers of older Australians from culturally and linguistically diverse (CALD) backgrounds who will require culturally appropriate care. The FECCA recommended that aged care providers have CALD strategies and training for staff in cultural competency.
The Aged Care Complaints Commissioner (Complaints Commissioner) advised that it had begun to use new channels to disseminate information, including producing videos on YouTube and using social media in order to reach out to the ‘next-generation cohort’.
Change in Culture
Anglicare Australia suggested that a change in culture in residential aged care is needed, and recommended a focus on the ‘purpose of care’, which it defined as ‘not only about avoiding harm, but … the wellbeing and the quality of life enjoyed by people in care’. Anglicare Australia acknowledged that achieving cultural change is difficult, ‘especially across large organisations and industries’. Further, Anglicare Australia stated that a ‘robust complaints and disclosure regime needs to sit alongside this sense of the purpose of care’.
Civil Liberties Australia put forward the view of an older Australian, who called for a change in culture around aged care:
… aged care in Australia is primarily regarded as in need of better management … but not needing an entirely different value given to old age. Nowhere is it seen as a priority to listen to and speak with elderly people themselves, as the main people that Aged Care should be for.
New Aged Care recommended a change in culture which focusses on the resident: ‘We need to go back to basics, with resident centred care the priority, where policies and procedures support rather than oppose the model’. Further, New Aged Care stated that the current aged care system does not see collaboration:
Our current situation where care providers work in silos with little or no collaboration between RACFs, accreditation bodies & medical services, results in dysfunctional, costly and at times inappropriate care for residents.
Professor Joseph Ibrahim suggested that international examples from Holland and Sweden offer good models, and stated that Holland and Sweden ‘care about the population and want to integrate them and have them as part of society’. Professor Ibrahim contrasted this with his view of the Australian aged care system, which was characterised as being driven by avoiding hospitalisation of older Australians.
Innovation in Residential Aged Care Facilities
Aged care providers described innovative models developed in response to consumer needs, and the positive effect these models had on residents. Innovative policies around dementia care were highlighted by Dementia Australia, who described the policies of the Grafton Aged Care Home for residents with dementia and others. After collaborating with Dementia Australia on staff education around the needs and wants of those with dementia, the Grafton Aged Care Home developed an ‘open doors’ policy in its secure dementia unit.
Following the open doors policy at Grafton Aged Care Home, Dementia Australia stated that the facility had developed an afternoon café and friendship morning, which allows residents to participate in meaningful activities while assisting staff workloads. Dementia Australia stated that as a result of this innovation, ‘staff members have witnessed a reduction in wandering and an increased appetite in residents when involved in the preparation of food’. The ‘Friendship Morning’ initiative provides one-on-one meaningful activities for residents to participate in, run by recreational activities officers and assistants in nursing with a sound knowledge of dementia care.
The Aged Care Guild highlighted the model of care used in Bupa’s residential aged care facilities. This model aims to deliver person-centred care through a multi-disciplinary team to achieve ‘better health outcomes for residents through access to medical services and choice in how and where they receive care’.
Box 5.1: Case study: Flying Squads
The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) stated that ‘flying squads’ are used in some regions to assess and (if possible) treat people in aged care facilities whose health is rapidly deteriorating, and potentially reduce the rate of hospitalisation. The ANZSGM described the process and stated:
We … have flying squads that go out urgently to see people who are deteriorating, so, instead of a resident in an aged-care facility deteriorating and being put in an ambulance and going to an emergency department, we now have a lot of teams that can urgently go out and see these people and assess them, and, through this mechanism, we've been able to reduce their hospitalisation by 90 per cent.
The ANZSGM stated that the flying squad: assesses the resident; talks to staff and family members; consults general practitioners; constructs a management plan; and provides treatment. This process takes place within two to four hours.
Box 5.2: Case study: Dementia Villages
Innovative approaches to residential aged care have emerged internationally and are being trialled in Australia, such as the ‘dementia village’ model of residential aged care facility.
In the Netherlands, the Hogewey Care Centre contains a specially designed village, known as Hogeweyk, with 23 houses for 152 older people with dementia. In this village, residents are grouped together based on their ‘lifestyle’ and characteristics and manage the household together, with the assistance of staff.
Washing and cooking are done each day in the houses, groceries are sourced from the village’s supermarket, and residents are able to move around the village’s gardens, park and square. The village has been designed to allow a continuation of the resident’s lifestyle and promotes autonomy and independence, while providing assistance.
A Tasmanian dementia village is currently being developed by Glenview Community Services and HESTA, with Australian Government funding. The ‘Korongee’ facility will be based on the Hogeweyk model and will see 15 homes set in a village setting which includes streets, a supermarket, cinema, café, beauty salon and gardens.
The Victorian Council of Social Service (VCOSS) highlighted a Homeshare program, which is based in Melbourne. The Homeshare program ‘matches older people living in their own home with people willing to provide some care and household maintenance in return for accommodation’. The VCOSS also drew attention to an intergenerational living trial in the Netherlands, which offers free accommodation within an aged care facility to students, in exchange for 30 hours per month of socialising with residents.
The VCOSS described trials of including childcare centres within aged care facilities, and stated that Playgroups Victoria had run playgroups in Victorian residential aged care facilities with positive effects:
Workers report people with dementia become more lucid and engaged chatting with toddlers, and children can learn a lot from engaging with older people. Intergenerational activities show older people that they are valued as individuals that still possess lifelong skills, rather than just being passive recipients of care.
Australia’s ageing population poses a significant challenge to the Australian aged care system as it currently operates. Although change has been observed, and a focus on the consumer has emerged, there remains a need for reform.
The model for operation and funding of aged care was designed at a time when the profile of the aged care sector was different. Consumer needs and expectations have changed as people enter aged care at a later stage in life, often with higher medical needs, and the aged care model has not adequately responded.
This report, along with so many other inquiries and it is assumed the Royal Commission, has or will find major deficiencies within the aged care sector. It is vital that Australians of all generations can have confidence that Australia will provide high quality aged care that allows people to live in dignity and with appropriate medical care.
The next generation of older Australians, the ‘baby boomers’, will place different demands on the standard and type of care provided in residential aged care facilities. Inquiry participants stated that the next generation will be more likely to demand a higher standard of care. This will require government to evaluate the adequacy of existing funding and how we fund aged care into the future.
Increasing numbers of Australians with dementia will also place significant strain on the aged care system. Alternative models of residential aged care have emerged overseas, and a ‘dementia village’ model of care will be trialled in Tasmania. Currently, 52 per cent of residents of aged care facilities have dementia. As dementia rates are expected to increase, the Committee is pleased that innovative new models of care are being explored.
Aged care providers have begun to respond to consumer pressure and have implemented new, person-centred policies, and have observed positive effects from these policies. The Committee encourages providers to continue thinking of innovations and responding to consumers as their needs and wishes change.
Strategies to grow the aged care workforce will require collaboration between the aged care sector and Australian Government, in order to ensure that the changing needs and increasing numbers of Australians in aged care receive the quality and type of care they require.
Mr Trent Zimmerman MP
12 October 2018