2.1
The standard of clinical care within the residential aged care facility (RACF) sector has been a slow-boiling issue of concern in the Australian public for some time. Reports of extreme incidents of poor care have become regular features in the media. However, these are nearly always dismissed by RACF provider groups as outlier events that do not represent the general standard of aged care services.
2.2
The incidents of poor care at the Makk and McLeay wards at the Oakden Older Persons Mental Health Facility (Oakden) in South Australia in 2016, some of which were found to be criminal matters, brought these concerns to a head and were the catalyst for a greater focus on the provision of clinical care services in RACFs and ultimately led to this inquiry.
2.3
This chapter explores recent standards of clinical care in RACFs, who delivers that care and under what kind of service model. These issues are essential to explore and understand before discussing how those clinical services should be regulated, which is the focus of this inquiry.
Clinical care in the aged care context
2.4
There is a clear schism in how different stakeholders view and describe what comprises clinical care across the RACF sector, who delivers clinical care, who is responsible for the standards of clinical care, and how those standards should be regulated.
2.5
The following section will define what comprises clinical care, explore the current clinical environment in RACFs and outline examples of recent standards of care.
What is clinical and medical care?
2.6
The terms clinical care and medical care are often used interchangeably. This inquiry report is using a broadly accepted definition of clinical care as all health care delivered by a health professional. Clinical care includes medical care, which refers specifically to the health care provided by a medical practitioner, often a General Practitioner (GP). It is important to note the Terms of Reference for this inquiry refer to both clinical and medical care.
2.7
The majority of day-to-day clinical care in RACFs is provided by nurses, both Registered Nurses (RNs) and Enrolled Nurses (ENs). The scope of practice for nurses is determined by the Nursing and Midwifery Board of Australia (NMBA), the relevant practitioner board within the Australian Health Practitioner Regulation Agency (AHPRA), and must be adhered to by nurses in order to retain professional registration. The nursing scope of practice, discussed in greater detail later in this chapter, outlines the kinds of clinical care within the aged care context that must be undertaken by a nurse, what can be delegated to a support worker and what, by exclusion, is an unregulated personal care practice.
2.8
In contrast, the difference between clinical care and personal care is not clearly defined in aged care regulatory frameworks, funding agreements or service contracts. However, personal care can be generally defined as any care which is not specifically delineated as clinical care. This issue is discussed in greater detail later in this chapter.
Current clinical environment
2.9
In reviewing the regulation of clinical care within RACFs, it is important to understand the environment in which that clinical care is being delivered. The committee received evidence that RACFs are home to communities of aged people who are frail, have chronic and complex health issues and minimal ability to access mainstream health services, and that these care needs are growing more complex every year.
2.10
In 2016, the majority of people in permanent residential care were rated as having high care needs. Between 2009 and 2016, the proportion of high-care residents with complex health care needs rose from 12 per cent to 61 per cent. Currently, the average Aged Care Funding Instrument (ACFI) subsidy for all age care recipients is 89 per cent of the maximum subsidy, further outlining the complex health care needs of RACF residents.
2.11
The President of the Australian and New Zealand Society for Geriatric Medicine noted that admissions to a RACF are generally triggered by a health need and that medical conditions, which are often multiple and interacting, are the main reasons for older people moving into aged-care facilities.
2.12
The Australian College of Nursing told the committee that the average person admitted to a RACF has significant high care needs, multiple diagnosed comorbidities and high acuity of conditions with polypharmacy, and requires a level of complex care that can only be delivered under the direct supervision of a RN. The Australian College of Nursing told the committee it would 'be fair to say that older Australians are admitted to aged-care facilities due to necessity, not to choice, and often at relatively short notice'.
2.13
The Australian Medical Association (AMA) has put forward the view that 'the aged care system as a whole, and its workforce, does not have the capacity, capability or systems integration to adequately deal with this growing, ageing population'.
Outcomes of clinical care
2.14
Examples of poor care are often dismissed by RACF provider groups as not representative of the generally high standard of care in RACFs across Australia. The Aged Care Guild submitted that 'critical incidents are largely isolated and reflective of poor leadership and oversight of staff adherence to care standards and existing practices and procedures'.
2.15
However, in recent years these individual incidents have begun to be looked at as a whole, forming a picture of a service sector that is plagued with regular and disturbing incidents of substandard care. The Aged Care Quality and Safety Commission (Aged Care Commission) told the committee:
As a sentinel event, Oakden was a shock wave right across the sector and right across the community. It was a wake-up call to providers and to consumers but also to the regulators.
2.16
Clinical care is one of the top five areas of non-compliance with the Aged Care Standards found by the Australian Aged Care Quality Agency (Quality Agency), which, as of 1 January 2019, was replaced by the Aged Care Commission. In 2016-17 the Quality Agency made 22 findings of serious risk, and in half those decisions a failure in clinical care was present.
2.17
As well as being one of the top non-compliance matters found by the aged care regulators, clinical care remains the main source of complaints received by the Aged Care Complaints Commissioner. Issues with the quality of clinical care were also raised as core reasons for sanctions imposed against providers managing the Makk and McLeay wards at Oakden.
2.18
The committee heard that care outcomes for RACF residents are worsening. The Brisbane North Primary Health Network (PHN) told the committee what 'we do see in our data is an increasing percentage of presentations at emergency departments by people in residential aged care requiring care'. This experience is replicated across Queensland and in other states. In Queensland overall there was a 17 per cent increase in aged care residents being transported to emergency departments in the year 2016–17 and Victoria reported an increase of 25 per cent in similar transfers in 2017.
2.19
The Queensland Nurses and Midwives' Union (QNMU) submitted that the evidence of significant numbers of inappropriate transfers from RACFs to hospitals points to a situation where RACFs lack the staffing and skills to practice effective primary health care and hospital avoidance. QNMU further cited this as an example of cost-shifting from RACFs to the acute care sector.
2.20
A Department of Health (Department) study estimated pressure injuries at a significantly high 26–42 per cent of RACF residents. Within hospital systems, pressure injuries are recognised as an issue of patient safety.
2.21
A national study by Monash University into premature and potentially preventable deaths in RACFs found that 15.2 per cent of all deaths of RACF residents were from external or preventable causes, almost all unintentional. Of those preventable deaths, the study found a very low incidence of death from complications of clinical care (1.2 per cent) while dying as a result of a fall was 81.5 per cent and choking 7.9 per cent. As outlined in evidence to the committee, certain clinical care practices around medications mismanagement and restrictive practices can increase the risk of falls.
2.22
The Older Persons Advocacy Network submitted a list of the types of RACF consumer health care issues raised with it.
2.23
Dementia Australia submitted a case study from a family member:
If Hell exists, this was it. The hallways echoed with moans and outcries from patients, begging nurses to come change them, crying from the humiliation of having to sit in their own muck and faeces for hours on end: "Help me! Please! Can anyone hear me? Please! This is no way to be!" It was horrifying. My mother's hygiene was not attended to by staff and nurses treated her like an inconvenience and a lifeless corpse. They had no respect for her well-being and treated her without dignity.
2.24
These examples can be compared to the statements from the Chief Executive Officer of the Quality Agency in February 2018, that the aged care system provided overall high quality care and the regulatory system was robust:
We believe that the Australian public can be assured that there are strong networks in government and that the public can feel assured that not only is there appropriate, safe and high-quality aged care but, if there are breaches in that system, that the complaints commissioner, ourselves and the department are all prepared to undertake our respective roles to ensure that any noncompliance or any risk is properly addressed.
2.25
This inquiry will not investigate clinical care standards with a view to proving there are legitimate concerns. The committee understands that, notwithstanding the defences put forward by the RACF sector, it is now a universally accepted truth that a poor standard of care is being experienced by too many RACF residents. The committee points to the Royal Commission into Aged Care Quality and Safety, which was called because of the level of non-compliance with care standards by providers.
Missed care
2.26
In addition to reports outlining the declining general health outcomes for RACF residents, a number of studies have recently been conducted to evaluate episodes of 'missed care' in RACFs. These studies attribute the increasing rates of missed care to reduced numbers of nurses as a proportion of the workforce, an issue discussed in greater detail later in this chapter.
2.27
QNMU submitted a definition of missed care alongside the results of an audit conducted to identify members' experiences of missed care episodes:
Missed care is manifested by the difficult decisions that care staff have to make in understaffed work environments in relation to such things as pressure injury care, falls surveillance, feeding residents, mobility assistance, assisting with activities of daily living and responding in a timely manner to requests for assistance.
Table 2.1: QNMU Missed care audit
|
Missed care issue
|
Percentage
|
|
Residents waiting longer than they should when they ask for assistance/help
|
80.49%
|
|
Not enough time to complete hygiene cares for residents
|
68.29%
|
|
Residents not being repositioned as often as needed
|
62.20%
|
|
Residents not being mobilised as often as needed
|
60.98%
|
|
Increased falls
|
57.32%
|
|
Not enough time to properly feed residents
|
57.32%
|
|
Not enough time to document care
|
51.22%
|
|
Other response or comment (please specify)
|
48.78%
|
|
No time for shift handover
|
47.56%
|
|
Increased pressure injuries
|
40.24%
|
|
Not enough time to attend/complete wound care
|
34.15%
|
|
Increased skin tears
|
31.71%
|
|
Medications being missed or not given at the right time
|
26.83%
|
Source: QNMU, Submission 6.1, p. 9.
2.28
The Australian Nursing and Midwifery Federation also conducted a study on staffing levels in RACFs, which included issues around missed care. The study found that, based on level of acuity and care needs, residents need four hours and 18 minutes of care per day, but the average being provided is 2 hours and 50 minutes. The staffing skills mix recommended by this study is discussed in chapter three.
2.29
The AMA also submitted concerns that low staffing levels in RACFs are a cause of missed care.
Committee view
2.30
The committee is highly concerned with the poor standards of clinical care being provided in some RACFs to vulnerable older Australians, who should be treated with respect and dignity. The committee remains sceptical of claims by the RACF sector that these events are outlier events, often the fault of rogue individuals, and do not represent the general standard of care. The committee notes that when these events are collated into a single body of evidence, they form a picture of an RACF service sector with an unacceptably high level of these 'individual' incidents of poor care.
2.31
The committee is highly concerned by evidence from Monash University that 15 per cent of all deaths in RACFs have preventable causes, and of these nearly 90 per cent are from falls and choking, which are associated with poor personal or clinical care. An avoidable-deaths rate of 15 per cent would be cause for outrage in any other care sector, and the aged care context should be no different.
2.32
The committee also notes the establishment of the Royal Commission into Aged Care Quality and Safety, a decision never taken lightly by governments, was in response to concerns with the standards of care being provided in some RACFs. It is now an all too common event that the standard of clinical care in some RACFs is unacceptably low and often does not afford either dignity or health and safety to individual RACF residents.
Aged care: supported accommodation or health care?
2.33
The committee heard differing views on how RACFs should be defined—as either home-like accommodation with support services, institutional care, or subacute health facilities. The different ways that stakeholders defined the type of service that RACFs provide tended to impact how the stakeholder then defined aged care as a health or personal care service, and the corresponding levels of regulation that would be appropriate.
2.34
South Western Sydney Primary Health Network (PHN) attributed much of this confusion to the aged care reforms undertaken in the late 1990s, which involve 'the removal of recognition as health care facilities when hostels and nursing homes were blended to form residential aged care facilities under the Aged Care Act of 1997'. South Western Sydney PHN stated this has led to a considerable watering down of the regulation of medical, nursing and allied health services in RACFs.
2.35
The Flinders University College of Nursing and Health Sciences submitted similarly that:
Nursing and nursing care have been taken out of the language of aged care since the 1987 reforms, in a deliberate attempt to reduce costs...As such, non-nurses are providing complex and intensive nursing care and administering medications without adequate training and with very limited supervision.
2.36
The Department's views on aged care appear to have changed. In August 2017, the Department submitted to the inquiry a definition of RACFs which omitted any reference to clinical care outside of providing 'access' to allied health services:
Residential care provides care and accommodation to older people who are unable to continue living independently at home. The services provided through residential care include personal care services (help with the activities of daily living such as dressing, eating and bathing); accommodation; support services (cleaning, laundry and meals); and access to some allied health services, such as physiotherapy. For people who need almost complete assistance with most activities of daily living, residential care can provide 24-hour care.
2.37
The Department later submitted to the committee a definition of RACF services in March 2019, which stated:
Residential aged care facilities deliver a range of care and services including personal and clinical care, as well as services and supports for daily living.
2.38
However, some RACF peak bodies and providers have submitted they are not responsible for any direct provision of clinical services. This position is outlined in greater detail in the later section on responsibility for clinical care.
2.39
The Royal Australian and New Zealand College of Psychiatrists (RANZCP) told the committee that although RACFs are intended to be a person's home under the Aged Care Act 1997, 'you can't get around the fact that there are staff who are employed by often a large organisation whose responsibility it is to run the home and to ensure that the home meets certain standards'.
2.40
The Australian Commission on Safety and Quality in Health Care (Health Care Commission) told the committee that in its view, RACFs are institutional care where the provider has ultimate responsibility for all care being provided:
There's no question about it. It's a home that's shared with many other people, so therefore it's a home that's provided in an institutional setting. Most people that are there are there because they can't look after themselves at home. So essentially aged-care facilities provide an institutional form of care.
2.41
QNMU provided a similar view to the Health Care Commission that positioned RACF services as an institutional model, and submitted that '[u]nder any plausible definition of the term, a residential aged care provider…is a health service provider within the context of aged care'.
2.42
Dementia Australia concurred with the view that defining RACFs as 'home-like' does not have to come at the expense of appropriate care quality standards, such as clinical governance. Dementia Australian further told the committee:
I don't know whether you've been to a lot of residential aged care facilities... but I have never seen one where I would walk into and go, 'Oh gee, this feels like home'!
2.43
QNMU stated that defining RACFs as a resident's home does not negate RACF provider responsibilities to deliver quality clinical care and told the committee:
...we've heard providers claim many times that a residential facility is a home and not a hospital or some other kind of facility... But the physical and welcoming environment is irrelevant to the standard of health care that is required for that person...While it is important that aged-care providers make their facilities as homely as possible, it does not abrogate their duty to provide safe, high-quality care in doing so.
2.44
The New South Wales (NSW) Nurses and Midwives Association went further and told the committee that the low standards of personal care and nursing did not meet a definition of 'home':
[T]he definition of 'home' is talked about in terms of it being a place of safety and happiness... In January we surveyed over 1,600 of our members. Poor staffing and skills mix of all levels of work meant 73 per cent had not had time to sit and talk with someone who was lonely in the past week, around half knew someone had missed a bath because they didn't have time to assist them, 44 per cent knew someone had missed wound care and 37 per cent knew someone had been left in pain too long... These are factors that impact on whether a place feels like home or not—whether, as the definition suggests, they're places of safety and happiness.
2.45
The Australian College of Nursing told the committee:
... the conditions we see in residents now illustrate quite clearly that aged care is health care. What we see with most aged-care facilities now is that, if they weren't called aged-care facilities, they'd be classed as subacute and non-acute hospitals, which means aged-care providers are, for all intents and purposes of what they do, healthcare providers.
2.46
QNMU submitted that RACFs are increasingly being used as hospices for frail older persons with complex care needs and are arguably 'more appropriately sub-acute, non-acute care facilities, being often little different in terms of the intensity of care to that provided in a Geriatric Evaluation and Management Unit in a hospital but without the specialist clinical and multidisciplinary features of this approach'.
2.47
The Aged Care Guild, a RACF provider body, told the committee there is a lack of a clear definition and goal for residential aged care and stated:
…we haven't defined what we want out of residential aged care. As you said earlier, it is someone's home. It used to be somewhere where you would live and get the level of support you needed to continue to live in that environment with independence. But increasingly it's being looked at as an opportunity to put people who are highly complex somewhere because there are blockages elsewhere in the system. Whether it's young people with disability or whether it's people with subacute needs where there are gaps, aged care does take this role quite a lot, and that's challenging. So we've got to be able to say what the role is.
2.48
The issue of appropriate service definitions was raised as a key cause of substandard clinical services at Oakden. In the review report, Oakden Report – Report of the Oakden Review (Oakden report), the SA Chief Psychiatrist found that the lack of an endorsed model of care 'led to a resultant further decline in services'.
2.49
The lack of an appropriate model of care being in place for most RACFs is a key factor in poor clinical care standards and is discussed later in this chapter.
What are RACFs funded to provide?
2.50
Prior to admission to a RACF all residents have been assessed by an approved, clinically trained health professional as having a frailty or disability requiring continuing personal care, taking into account their medical, physical, psychological and social circumstances. The My Aged Care Assessment Manual defines RACF services as 'Permanent Residential Care which incorporates, personal care, nursing care, or both, that is provided to a client in a residential facility in which they are also provided with accommodation'. It should be noted that in disability services, accommodation providers are banned from also being service providers due to conflict of interest issues for residents. This issue is explored in chapter three.
2.51
Following admission, the RACF provider conducts an appraisal using the Aged Care Funding Instrument (ACFI) to determine the level of care to be provided to meet the resident's needs and establish the level of the Australian Government subsidy.
2.52
The Combined Pensioners and Superannuants Association submitted that despite RACFs receiving funding under the ACFI for residents with high care needs, many RACFs do not provide fulltime access to a RN to deliver this care. The AMA concurred with this view and submitted that RNs are being increasingly replaced with personal care workers/Assistants in Nursing (AINs) and some RACFs do not have nurses staffed after hours.
2.53
South Western Sydney PHN submitted:
Facilities receive funding through the Aged Care Funding Instrument (ACFI) to provide nursing care and assessment, planning and treatment by qualified allied health professionals. But, we are witnessing the reduction in numbers of Registered Nurses working in RACF’s and an increase in assistants in nursing and instances of untrained "aids" e.g. a "physio aid" being substituted for a qualified allied health professional.
2.54
Discussion on the suitability of the ACFI funding model and the overall levels of funding for aged care and its impact on clinical care standards is contained in chapter three.
Committee view
2.55
RACFs lack a clear and consistent definition of whether or not they are, or at least include, health services. This lack of operational definition impacts all subsequent decision making on how the services should operate, be managed, be staffed and importantly, how they should be regulated, which is the focus of this inquiry.
2.56
It is quite clear to the committee that, at minimum, RACF operators are paid to provide clinical health services in addition to other personal care services, to a cohort of people with high acuity, complex health needs and minimal to nil capacity for independent management of their needs.
2.57
The committee gives weight to the view that these definitional problems had their inception in the reforms undertaken with the merger of aged care hostels, places of minimal support for residents with a large capacity for independence, with nursing homes, designed for people with no capacity for independent living. The laudable move to make nursing homes appear more homelike and less starkly clinical has had the unintended consequence of making nursing homes perform with less clinical rigour, with a reduction in overall clinical care standards, governance and regulation.
Responsibility for clinical care standards
2.58
A key theme throughout this inquiry has been the differing views from RACF providers, clinicians and regulators on what comprises clinical care within the aged care context, and who should be responsible for meeting those standards.
2.59
HammondCare, a RACF provider, did not address the issue of clinical care in its submission and instead focused on the provision of medical care. HammondCare submitted that RACFs are only responsible to assist residents in accessing the services of medical practitioners as required and therefore this was not an issue for the aged care regulator to assess. In contrast, the AMA cited difficulties faced by GPs in seeing patients who are residents of RACFs, and argued that access to medical care should be an explicit regulated standard. Access to medical care is discussed in greater detail later in this chapter.
2.60
HammondCare did submit that RACF providers provide nursing services, but made no comment on whether they consider this to be clinical care, or how that clinical care should be regulated. In response to the premise that clinical care is only provided by external health practitioners and not by nursing staff of RACFs, QNMU told the committee that:
...we hear, many times, aged-care providers and their advisers claiming that nurses do not provide clinical care; that such care comes largely from general practitioners and allied health. In our view, it is a nonsense to suggest that nurses do not provide clinical care or, indeed, that residents do not need nursing care and highly skilled nursing practice.
2.61
QNMU pointed to the Fair Work Commission Nurses Award 2010 which all private sector RACF providers must comply with, which described the work of a nurse as 'delivering direct and comprehensive nursing care, and coordinating services, including those of other disciplines or agencies, to individual patients, residents or clients'.
2.62
QNMU further noted enterprise bargaining agreements which describe the nursing role in aged care includes responsibility to 'monitor outcomes of clinical practice; possess advanced clinical level skills; provide nursing care within the scope of clinical practice; and provide expert clinical advice relating to complex care issues'.
2.63
Aged and Community Services Australia, a RACF provider peak body, submitted what appeared to be a view that changed during the course of this inquiry. In August 2017, it submitted that the aged care quality assurance framework should 'focus on the quality of aged care provided rather than the professional standards of individual medical and nursing staff which are covered by other mechanisms'. Aged and Community Services Australia did not submit why it considers the quality of aged care not to incorporate the clinical care services RACFs are paid for under the ACFI. However in March 2019, it submitted that aged care regulators do in fact regulate clinical care and 'have clear powers in relation to approved providers who do not meet the expected outcomes' of clinical care as outlined in the existing Accreditation Standards and incoming Aged Care Quality Standards.
2.64
The position put forward by some RACF providers, that clinical care standards are a matter of individual professional performance, does not acknowledge that where an AHPRA investigation finds that if the organisational environment has contributed to the substandard clinical care of an individual health practitioner, it is standard practice for AHPRA to refer that issue to the relevant regulator for investigation of systemic issues. In the case of aged care, that would be the Aged Care Commission, formerly the Quality Agency.
2.65
The position that AHPRA is the suitable regulator of clinical care in RACFs on the basis of individual professional standards does not acknowledge the requirement in the existing, and soon to be implemented new standards, that RACF providers have a responsibility to ensure compliance with those professional standards. Chapter three includes discussion on how this responsibility is regulated.
2.66
Allied Health Professions Australia submitted that while the regulators of individual health professionals determine core competency standards and set out codes of conduct, 'they do not monitor practice, are agnostic to where individuals are employed and do nothing about individual practice until something goes wrong and a formal complaint is made. It is not in their remit to undertake quality auditing'.
2.67
Allied Health Professions Australia told the committee that responsibility for standards of care lie with both the individual practitioner and the workplace environment to provide 'a system of clinical governance that assures there is continual monitoring of care quality and focuses on a system of support and continual improvement of staff'. Allied Health Professions Australia went on to state that the current regulation of individual practitioners and the accreditation of RACFs was not enough to ensure standards of care on a day-to-day basis. Allied Health Professions Australia outlined a need to be more prescriptive of minimum levels of access to care, citing this aligns with recommendations of the 2018 report of the Aged Care Workforce Strategy Taskforce (Aged Care Taskforce), A matter of care.
2.68
The Older Persons Advocacy Network noted the important role the Quality Agency played in monitoring clinical care as it is often only the quality assessors who pick up gaps in care communication such as when there has not been clinical communication of the care plan to the care team. The Older Persons Advocacy Network further pointed to supporting material for the new Aged Care Quality Standards which state:
Health professionals, such as doctors, nurses and pharmacists provide clinical care. Organisations providing clinical care are expected to make sure it’s best practice, meets the consumer’s needs, and optimises the consumer’s health and well-being.
2.69
The Healthcare Commission was very clear in expressing its views and told the committee:
...like a hospital, a school or any other institution, an aged-care facility has duties of care to all of its residents, so the person in particular is owed a duty of care if it's someone who is very vulnerable or dependent and they need to be protected within that institutional care setting.
2.70
QNMU pointed out that the Quality of Care Principles require RACF providers to ensure there are sufficient human resources to meet the residents' needs. QNMU further submitted that although the existing Quality of Care Principals articulate that providers must have systems in place to ensure compliance with professional standards and guidelines, this requirement is now absent from the principles of the Single Aged Care Quality Framework (Single quality framework) and has been relegated to the Aged Care Standards Guidance Material.
2.71
The Aged Care Commission provided a number of very clear responses to the committee on its position regarding responsibility for clinical care standards:
The Commission considers residential aged care facilities to be services which deliver clinical care.
Nurses (registered and enrolled) provide clinical care in residential aged care facilities, alongside medical practitioners and allied health practitioners.
The approved provider is responsible for care standards, and the quality and safety of the care provided to consumers at the residential service.
The approved provider is responsible for supporting the safe practice of its individual staff.
Committee view
2.72
There appears to have been greater focus placed on the clinical aspects of aged care since the critical clinical care failures that occurred at Oakden. During the course of this nearly two year inquiry, evidence suggests the attitude of RACF providers has changed, and there is now nominal acceptance that aged care does in fact include aspects of clinical care. It is disturbing that a recent view was held by some RACF providers that they held no responsibility for clinical care standards, even though this responsibility was included in the accreditation standards they were assessed by, and were supposed to be operating under.
2.73
Despite some progress, there still remains disagreement on definitional issues of clinical care. The RACF sector is clearly in need of more explicit guidance material on what comprises clinical care and who is responsible for the different aspects of clinical care standards.
RACF model of care
2.74
As outlined earlier in this chapter, the lack of an appropriate model of care was a key concern of the Oakden report, which found that this contributed to the substandard clinical services.
2.75
The Oakden report provided a definition of a model of care as:
…Model of Care is defined as the way that health services are delivered, drawing on best practice care and services for a person, population group or patient cohort as they progress through the stages of managing a healthcare condition. A Model of Care articulates how people can access the right care, at the right time, from the right team in the right place.
2.76
Throughout this inquiry, the committee received evidence from a range of expert witnesses and submitters on the model of care under which RACFs deliver personal and clinical care. Submitters raised particular concerns that there is no industry standard model of care, and many RACFs operate without a clearly defined individual model of care. The informal model of care the industry operated under was referred to as a 'delegated model of care' and is described further below.
2.77
Dementia Australia told the committee that work needs to be done to more clearly define the difference between personal care and clinical care and define who is responsible for which aspects. The Office of the Public Guardian Queensland (Qld) supported this view and submitted that an appropriate model of care needs to be developed for persons with dementia, aimed at managing challenging behaviour and based on ensuring dignity and respect.
2.78
The Older Persons Advocacy Network raised similar concerns and outlined the critical need for very clear guidelines to delineate where clinical care starts and finishes, as the delegated model of care involves a workforce with limited or indirect supervision from registered clinical professionals. The Older Persons Advocacy Network noted this care model also heightened the need for good clinical governance.
2.79
Aged Care Services Australia, a peak body for RACF providers, told the committee that '[m]any approved providers across the sector would have in place clinical frameworks, these would range from those developed in-house through to the adoption of models based on nationally developed principles'.
2.80
Bupa is one such provider which has established its own Bupa Model of Care, which comprehensively outlines delivery of care through a multidisciplinary team. It must be noted however, that despite having an established model of care, Bupa has experienced a significant care deficit with 9 of its RACFs being sanctioned within a 12-month period for failing to meet compliance standards, with some identified as a 'severe risk to the health, safety and wellbeing of care recipients'.
2.81
Occupational Therapy Australia identified problems with the model of care in relation to allied health professionals, citing that it is usual practice for RACFs to outsource allied health services and then confine those people to very limited roles. This severely restricts their capacity to be involved in critical preventative health issues such as environmental assessment and intervention, falls management and the non-pharmacological treatment of behavioural and psychological symptoms of dementia (BPSD).
2.82
Allied Health Professions Australia recommended that aged care reforms should include work to identify best practice models of care for different facilities and patient cohorts, and identify the necessary roles and staffing needed to support the needs of those residents.
Informal model of delegated care
2.83
Submitters and witnesses described to the committee how day-to-day personal and clinical nursing care is delivered to RACF residents. The model was often referred to as a 'delegated model' where a registered health practitioner, generally a RN, assessed the personal and clinical care needs of the resident, determined the level of skill required to meet those needs, and delegated appropriate aspects of personal and/or clinical care to other health practitioners or to AINs.
2.84
The Australian Nursing and Midwifery Federation noted that decisions about whether the personal care should be provided by a nurse or another level of worker can only be made by the RN, and must be consistent with the Nursing and Midwifery Board of Australia (NMBA) Decision Making Frameworks. Decisions must be based on the characteristics of the person requiring care, the activities to be performed, and the competence, education and authority for practice of the person providing the care. The NMBA further defines work that AINs are authorised to provide as 'routine client-specific activities requiring a narrow range of skill and knowledge'.
2.85
QNMU made similar observations about the requirement for RNs to evaluate the difference between clinical and personal care and noted that, under the Health Practitioner Regulation National Law Act 2009, only a RN is authorised to determine a resident's nursing needs, and therefore by exclusion their personal care needs. QNMU noted that the clinical assessment and care delegation by a RN is essential to ensure that the AIN does not provide care they are not qualified to perform. QNMU further noted that it is a mandated requirement by the NMBA that the RN must evaluate the outcome of the delegated episode of care. The Australian College of Nursing submitted that changes in NSW to remove the requirement for a RN to be present in an RACF at all time, is incompatible with nursing registration requirements that ENs and AINs are supposed to work under the direction of a RN.
2.86
QNMU noted that the delegation model is a result of not enough nurses being employed to undertake the personal and clinical care requirements of RACF residents, and to address this 'aged care providers employ unregulated healthcare workers…to assist the RN'. QNMU further noted that the limited numbers of nursing staff 'forces RNs into a situation where they are prevented from complying with their statutory duties' such as evaluating the outcomes of delegated care performed by an AIN.
2.87
The Older Persons Advocacy Network raised concerns with the delegation model, submitting that the majority of care in RACFs is now undertaken by 'a large, unstructured workforce of personal carers and AINs who provide direct care with no regulatory safeguards or accountability'. The Older Persons Advocacy Network has recommended the model of care should include formal supervision arrangements for these staff. Discussion on the possible regulation of non-clinical staff is included in chapter three.
2.88
The Quality Aged Care Action Group (QACAG) submitted its concern with the recommendations of the Aged Care Taskforce, which promotes the role of a care manager who does not need to be a RN. QACAG pointed out that RNs cannot receive clinical supervision from a person who is not also a RN, and questioned whether a person who is not clinically trained can provide effective supervision, particularly in the areas of medication management.
2.89
The issue of nursing ratios and the regulation of AINs is discussed in greater detail in chapter 3.
Clinical governance
2.90
Clinical governance is an essential component of a model of care. The Department defines clinical governance as 'a systematic and integrated approach to assurance and review of clinical responsibility and accountability that improves quality and safety resulting in optimal patient outcomes'. The Health Care Commission defined it as 'the set of relationships and responsibilities established by a health service provider, the governing body, executive, clinicians, patients, consumers and other stakeholders to ensure good clinical outcomes'.
2.91
Many submitters and witnesses raised concerns with the lack of appropriate clinical governance in RACFs and the impact this is having on clinical standards.
2.92
The Australian College of Nursing submitted that clinical governance is 'vital to ensuring clinical care is safe, effective, appropriate and person-centred' but while clinical governance frameworks are well established in the healthcare system 'there is no agreed clinical governance framework for aged care providers in Australia from ACN’s understanding'.
2.93
Professor Edward Strivens of the Australian and New Zealand Society for Geriatric Medicine noted that 'clinical governance is embedded in absolutely everything we do' in a health setting.
2.94
QNMU told the committee that the lack of focus on clinical governance in RACFs could be attributed to the fundamental lack of recognition about RACFs being healthcare environments. QNMU further submitted that the lack of clinical governance results in a system that is set up to fail because stakeholders fail to recognise the clinical risks.
2.95
The Aged Care Commission presented evidence that clinical governance is an issue that is covered in the existing Accreditation Standards, and this requirement has been further strengthened in the incoming Single quality framework. These standards, and how they are regulated, are discussed in chapter three.
2.96
The Older Persons Advocacy Network pointed to the clinical governance frameworks developed by the Health Care Commission, and recommended the Aged Care Commission and its Chief Clinical Advisor undertake work to develop a similar national model for the RACF sector. This work has since begun, with the Health Care Commission working collaboratively with the Aged Care Commission. This project is outlined in chapter three.
Medications issues
2.97
The complex clinical environment of RACFs, as outlined earlier in this chapter, extends to the medications environment. It has been estimated that RACF residents have an average of 3.4 to 4.5 separate diagnoses and are taking 8.1 medications. Polypharmacy is defined as the use of five or more drugs, which includes prescribed, over-the-counter and complementary medicines. Polypharmacy is described by Australian Prescriber as being associated with suboptimal prescribing, is a barrier to adherence, increases risks of adverse drug events and falls, and makes it harder to obtain an accurate medical history.
2.98
In this environment, medications management is a key component of appropriate clinical governance. Medications management includes: ensuring people are appropriately diagnosed and prescribed the right medications; appropriately managing polypharmacy to address contraindications; regular medication review to ensure de-prescribing occurs; medications dispensing by an appropriately qualified person; and ensuring that assistance in taking medications is done by an appropriately skilled and/or qualified person, which includes assessment of the individual patient to determine the level of assistance required.
2.99
The Quality Agency submitted information on the extensive evidence it required RACF providers to demonstrate during assessment visits to show that medications are managed safely and correctly. Despite this, medications management was one of the top five complaint areas reported to the Aged Care Complaints Commission, showing this is an issue of concern in RACF service delivery. The Department also pointed out that although it provides a number of resources to assist RACF providers with safe medication management processes, it is the responsibility of providers to ensure medications are administered safely.
Administering medications by unregulated care workers
2.100
Clinical organisations have expressed concern with the trend in the RACF sector of delegating some medications tasks from nurses to unregulated carers, particularly in light of the state and territory laws around medications dispensing to people with cognitive impairment.
2.101
Guidance material from the Australian Nursing and Midwifery Federation outlines that the AIN role is limited to 'assisting older people with self-administering their medicines from prepackaged dose administration aids' and this is limited to older persons who have been assessed by the RN or prescribing practitioner as being safely capable of administering their own medicines. The Australian Nursing and Midwifery Federation has expressed concern that 'in some circumstances assistants in nursing...are being directed to administer medicines to residents in aged care facilities'.
2.102
QNMU cited the Health (Drugs and Poisons) Regulation 1996 (Qld) which requires that carers are only able to assist with medications when asked by cognitively competent individuals. The NSW Nurses and Midwives Association noted that guidelines designed for unlicensed care workers to assist people to self-administer medications were not intended for the current RACF environment of high care. As discussed later in this chapter, over half of RACF residents have dementia, meaning the overall numbers of people in RACFs who are cognitively competent to self-administer is low.
2.103
Despite state and territory laws which, in some locations, allow AINs to assist with taking medications, the Combined Pensioners and Superannuants Association (CPSA) raised concerns with the increasing use of dose administration aids such as Webster packs being used by AINs. In its submission the CPSA cited a 2008 study of the packaging of dose administration aids finding packing errors in 34 of the facilities at rates between one per cent and 54 per cent, and pointed out that AINs are not trained to identify these errors or know how particular medications interact.
2.104
The CPSA further pointed to the prescription of pro re nata (as needed) medications, as in NSW schedule 4 or schedule 8 pain medications can only be administered under the direct supervision of a RN. As many RACFs may not have a RN on site at all times, residents are sometimes unable to access their pain medications when needed.
2.105
The regulation of medication standards is made more complex as aged care regulation is a federal issue, while medication dispensing is regulated by state and territory legislation. This regulatory challenge is discussed in greater detail in chapter 3.
Medications safety
2.106
RANZCP told the committee that medication management procedures used in health settings, such as cross checking during dispensing, were often not used in RACFs and also noted that for consent purposes, families could feel pressured by the RACF to accept the prescription of psychotropic medications without properly understanding the outcomes for their family member.
2.107
The Australian College of Nursing pointed to a recent study conducted by Macquarie University which selected 203 residents from 53 different facilities, and found that on a randomly selected day, these 203 residents received more than 5000 medication orders of more than 400 different medications, and stated that '"Polypharmacy" really is an inadequate word for the reality'.
2.108
Occupational Therapy Australia made similar observations that, while the majority of RACFs manage medications appropriately, problems predominately arise from insufficient staffing, excessive workloads and the use of agency staff. It also noted that medication is sometimes prescribed on the basis of nursing reports, with GPs not always visiting clients prior to prescribing.
2.109
Allied Health Professions Australia told the committee that overmedication is often a result of understaffing and insufficient access to appropriately qualified allied health workers, combined with poor clinical governance processes.
2.110
The Older Persons Advocacy Network told the committee that often medications are prescribed as 'as required' but without a proper monitoring system of how often these are being used there is a risk of overuse of the medications.
2.111
The Chief Medical Officer from the Health Care Commission noted it is difficult to get a medication review done properly in a RACF. The Office of the Public Guardian Qld submitted a similar view that where a doctor has prescribed a medication, the RACF will administer it without questions, without providing additional safeguards such as independent oversight or medications reviews.
2.112
The Australian College of Nurse Practitioners submitted that the focus on how medications are handled loses sight of the key concern, which is 'whether the medication actually prescribed is appropriate and benefits outweigh the potential risks or harms associated with it'.
2.113
The AMA submitted that a more contemporary medical records system, discussed in greater detail below, would significantly reduce the risks associated with 'polypharmacy, and in turn reduce the likelihood of cognitive impairment, delirium, frailty, falls, and mortality in RACFs'.
2.114
The Health Care Commission told the committee that it has undertaken discussions regarding medications reviews in RACFs, and the community pharmacies have indicated they are keen to play a role in improving this aspect of medications in RACFs.
Medical records
2.115
The issue of poor medical record keeping in RACFs was raised by a number of stakeholders.
2.116
The South Western Sydney PHN told the committee of the work being done to improve the ability of clinicians to share medical records and datasets, such as 'health referrals, secure messaging, interoperable records and the like' but noted the system 'tends to break down once a person goes into a residential facility. A lot of [records in] residential aged care facilities are still paper based, for example. The linkages just aren't there'.
2.117
The Australian College of Nurse Practitioners submitted that medical record keeping needs to be updated with a digital strategy to ensure 'appropriate and timely information is available to support decision making for frail and vulnerable' residents.
2.118
Allied Health Professions Australia noted that poor record keeping may have a significant impact on the quality of clinical care provided by allied health professionals.
2.119
The Brisbane South and Brisbane North PHNs submitted that the current medication records system is 'prone to clinical risk, medication errors and inefficiencies' and the 'format of the charts used in aged care complicates transmitting a comprehensive record of a resident's current treatments'. The two PHNs recommended the 'National Residential Medication Chart' be moved from a paper based system to a more modern and efficient digital system which would link doctors and pharmacists with the RACF.
2.120
The Australian and New Zealand Society for Geriatric Medicine submitted that a lack of effective record keeping impacts both safety and quality of care. RANZCP made similar observations and submitted that 'the standard of record-keeping is poor, often containing material that is of little clinical relevance'.
2.121
The recently implemented My Health Record presents opportunities to improve the coordination of health data for individual residents. A pilot project undertaken by the Central Queensland, Wide Bay, Sunshine Coast PHN with the Australian Digital Health Agency and Benevolent Aged Care in Rockhampton found enhanced care outcomes when My Health Record is 'embedded into clinical workflows such as admission processes and medications reviews'. However this would require the RACF provider to have a compatible digital health record system.
Committee view
2.122
The concluding committee view in the interim report for this inquiry stated:
Of particular concern to the committee is the body of evidence relating to model of care issues, definitions of personal versus medical care, and clinical governance within aged care facilities.
2.123
After deeper investigation, the committee remains of the view that a fundamental problem with acceptable clinical care standards in RACFs lies in the lack of appropriate rigor in the approach to planning how to deliver those services. As there is no specific industry-wide model of care and no regulatory framework which specifies how care should be delivered, the model of care used in RACFs appears to be one that has developed informally over time and appears to be largely based on finding costs-savings within the requirements of, or bypassing, the nursing scope of practice.
2.124
Not only is there no defined model of care for the RACF sector, there is no clear definition of what 'care' is, and where the lines between clinical and personal care begin and end. Without this planning, service delivery is ad hoc, inconsistent in quality, and relies too heavily on individual actors within the sector to maintain standards.
Specialist clinical care
2.125
Beyond day-to-day nursing care, RACF residents receive other kinds of clinical care from their RACF provider, including specialist nursing care, and care provided by allied health professionals such as psychology, podiatry, speech pathology and audiology. This care from allied health professionals can be provided by in-house staff or by external staff, often subcontracted from a health provider.
2.126
Allied Health Professions Australia told the committee that it believes the aged care system is failing older Australians, particularly in relation to access to allied health care which is closely linked to the maintenance of capacity and functionality for older people and is of particular importance for the clinical care standards for people with dementia and complex behaviours. The Older Persons Advocacy Network also noted the limited access to behavioural advice and supports to deal with challenging behaviour.
2.127
Allied Health Professions Australia further told the committee that access to allied health is not made a priority in many RACFs, and allied health staff typically work in RACFs on a part time or contract basis, 'limiting their ability to contribute to the application of appropriate clinical standards'.
2.128
However, Benetas submitted that these contract arrangements sometimes impact the ability that RACF providers have to insist on high clinical standards, as RACF providers do not have direct control over these allied health staff. Benetas submitted that there have been cases where instances of poor professional practice by these external allied health professionals have been raised by the RACF provider with their employer, but no action has been taken.
2.129
This issue highlights the recommendations by Dementia Australia that 'the roles and responsibilities of aged care staff and medical practitioners as they relate to the personal care, clinical care and medical care of a resident with dementia, need to be clear, with clinical governance structures in place that underpin and enforce those roles and responsibilities'. A discussion on dementia-specific care is included later in this chapter.
2.130
Bupa submitted that allied health services are vitally important to meet the health and care needs of RACF residents, and should be important factors when assessing aged care quality.
2.131
The issue of regulating appropriate use and standards of allied health services is discussed in chapter three.
Palliative care
2.132
Palliative care is an important issue in clinical care within RACFs, particularly given the increasing acuity in incoming residents and the shorter length of time people are resident in RACFs prior to dying. In 2010–11, 75 per cent of the 116 481 people aged at least 65 years who died in Australia had used aged care services in the 12 months before their death. The Chief Medical Officer for the Department noted that 'residential aged care has become to some extent, in part, a palliative care environment'.
2.133
Pain Australia submitted that appropriate palliative care is not available in RACFs, and raised concerns with 'inadequate pain management, inappropriate hospitalisation or medical intervention, and a lack of timely and appropriate consultation over their choices regarding end of life care'. Pain Australia further submitted that ensuring high quality palliative and end-of-life care services in RACFs will enable more older Australians to have a good death, and facilitate the better allocation of scarce health resources.
2.134
South Western Sydney PHN also raised concerns with the level of appropriate palliative care being provided in RACFs and submitted it results in 'inappropriate referrals to specialist care for people whose palliative need can be attended by a generalist team if good systems and staff training were in place in facilities'.
2.135
The Clinical Director for the Health Care Commission told the inquiry that providing palliative care 'takes high intensity nursing to be able to provide that and a rapidly responsive workforce who can address people's symptom issues...and that's the crucial issue that needs to be addressed'.
2.136
The AMA submitted that for palliative care, transfer to an acute care setting does not necessarily respect the needs of patients, as the acute care sector prioritises treating disease and preserving life. The AMA contended that people should be cared for in the environment of their choice and that the majority of Australians wish to die in their own home, which for many is a RACF. However, the AMA pointed out that there is a lack of resources to support this choice and recommended that RACFs have 'supporting policies in place that allows the generation of clear advanced care plans appropriate for the RACF setting, that are taken seriously and reviewed regularly'. This could be supported by 'hospital in the home-type services' provided by a Local Health Directorate.
2.137
The Aged Care Guild told the committee that the key factor missing in palliative care is assessment and planning for the needs of the individual and how the family want to meet that need. These needs are broader than just clinical care needs and include supporting the family and the patient's social and emotional health and wellbeing. The Aged Care Guild went on to state that there were enormous benefits to improving home-based palliative care, because 'you can better support someone at home, give them more care, better care and more dignity through death for almost half the price that you can do it in a hospital environment and leave the hospital bed free for someone who needs elective surgery'.
2.138
The Aged Care Guild advised the committee that fixing service delivery issues in home-based palliative care would take a multidisciplinary approach involving different levels of government funding, control and engagement, and that coordination of these different government levels was critical.
Pain management
2.139
Appropriate pain management was raised as an issue of concern by submitters and witnesses. The NSW Nurses and Midwives Association made a link between nursing staff ratios and pain management, noting that '[f]acilities that provided registered nurses on site at all times were more likely to be able to provide prompt pain relief and make informed clinical judgments about the appropriateness of medication administration'.
2.140
Pain Australia made similar observations and submitted that while chronic and acute pain is common among RACF residents, it is poorly managed or undertreated, including the suboptimal use of analgesics. As noted earlier in this chapter, the lack of a RN being on site at all times means that residents sometimes cannot access appropriate pain medications when needed.
2.141
RANZCP also noted that up to 60 per cent of people with BPSD will have unrecognised or undertreated pain. The Chief Medical Officer of the Health Care Commission also noted this as an issue of concern, and told the committee that '[i]t is when people who are dementing... get an infection, have a fever or are in pain and that makes their behaviour difficult'.
2.142
Pain Australia concurred with this view, and submitted that evidence shows that people with dementia are being under-treated for pain, compared with cognitively intact persons, and that this is a significant factor in BPSD.
Mental Health
2.143
The Mental Health Commission of NSW submitted that older Australians living in nursing homes have some of the highest rates of depression and anxiety, yet most RACF residents are unable to access Medicare-funded psychological care due to specific exclusions in the Aged Care Act 1997 and Medicare regulation. The Mental Health Commission of NSW argued this exclusion constitutes systemic neglect and a denial of human rights involving discrimination on the basis of age and infirmity.
2.144
Allied Health Professions Australia also raised the issue of mental health in RACFs as an issue of concern and submitted that more than 50 per cent of RACF residents have anxiety and/or depression.
2.145
RANZCP told the committee that Australians over the age of 75 are the most likely to be prescribed antidepressants, benzodiazepine sedative or psychotropic medications, but are also the least likely to see a psychiatrist, a clinical or other psychologist or allied health service related to mental health. RANZCP described this further:
So, we've got the group which is vastly overrepresented in terms of psychotropic prescriptions being the least likely people to have their care supervised by a specialist mental health practitioner, whether that's a psychiatrist or anybody else.
...
The conclusion that we draw is that this polypharmacy—this overprescribing; this lack of access to mental health services—is really driven by the needs of a large group of people in residential care who have a dementia diagnosis and are receiving psychiatric medications inappropriately.
2.146
The South Western Sydney PHN submitted that PHNs have recently been tasked with the co-design and delivery of psychological services within RACFs, and through this process have identified a key challenge is the lack of capacity in RACF staff to identify and adequately address the mental health issues of residents.
2.147
HammondCare raised similar concerns with appropriateness of delivering specialised mental health services in RACFs, and recommended that all Older Persons Mental Health services should be delivered in sub-acute health facility settings, while dementia care for all but most severe cases could remain in RACFs.
Dementia
2.148
The standard of care for people living with dementia in RACFs was raised as a major issue of concern by many witnesses and submitters. Concerns included the lack of non-pharmacological interventions being used, physical and chemical restraint being applied indiscriminately, and the communication barriers presented by dementia not being appropriately addressed, resulting in a lack of overall clinical care such as pain management.
2.149
Dementia Australia submitted that the care and support of people with dementia is one of the largest healthcare challenges facing Australia, with more than 410 000 Australians living with dementia. Dementia is the second leading cause of death, contributing to 5.4 per cent of all deaths in males and 10.6 per cent of all deaths in females each year.
2.150
Dementia Australia told the committee that over half of all RACF residents have a diagnosis of dementia, which 'suggests that dementia is core business for aged care providers'.
2.151
The Office of the Public Guardian Qld submitted that dementia is different to other cognitive conditions as it is terminal and cannot always be addressed through traditional positive behavioural support or by antipsychotic medication.
2.152
RANZCP pointed to best practice guidelines for managing patients with dementia which emphasise the importance of comprehensive assessments and non-drug interventions, with psychotropics as a last resort, and stated the 'current state of practice in aged care in Australia sees the reverse situation predominating'.
2.153
Occupational Therapy Australia made a similar observation on best practice, but submitted that non-pharmacological interventions are primarily led by allied health professionals and this is often the professional group most under-represented in RACFs.
2.154
Dementia Australia told the committee they are often given examples of care 'in which people living with dementia in residential aged care are overmedicated, physically restrained, bored, agitated or lonely'. Dementia Australia went on to outline a comment made by one of their carers:
In another life, I inspected nursing homes. That is why I choose to keep my father at home when he developed dementia. We have seen many providers that make the minimum standards, but in those same places I have seen people time and again drugged up and tied up.
2.155
The Office of the Public Guardian Qld submitted an example of a non-verbal woman in a RACF who was being held in restraints for up to 12 hours per day, was screaming all the time, had been assaulted in the chair by another resident and was on an excessive amount of medication.
2.156
Pain Australia submitted that people living with dementia 'have shared stories of an aged care system unable to meet their needs with reports of incidences that span physical, psychological and sexual abuse; inappropriate use of restraints; unreported assaults; and people in extreme pain at end-of-life not having access to palliative care'.
New dementia clinics
2.157
Dementia Australia submitted that the needs of people with dementia are not being fully supported through current mainstream RACF services, and demand is growing at a faster rate than the supply of aged care services. Dementia Australia recommended an approach that combines capacity building in mainstream services to provide quality care, along with the integration of specialist dementia services.
2.158
This approach has recently been undertaken by the Australian Government in the announcement of $70 million per year funding to establish more than 30 specialist care units, at least one in each PHN area, to provide care for people exhibiting very severe BPSD. The Specialist Dementia Care Program will include a nationally-consistent needs-based assessment framework, and centres will provide person-centred and multidisciplinary care with formalised arrangements for regular specialist clinical input and review.
2.159
The interim report for this inquiry recommended that all dementia-specific RACF services should be regulated as a health facility, echoing the concerns raised by the Health Care Commission in its recommendations to the Carnell Paterson review. However, the Health Care Commission has since advised the committee that the approach of the Specialist Dementia Care Program to incorporate specialist clinicians, including geriatricians or psychogeriatricians, will 'largely address the concerns'.
Restrictive practice and medications
2.160
Restrictive practice refers to 'any practice or intervention that has the effect of restricting the rights or freedom of movement of a person with disability, with the primary purpose of protecting the person or others from harm'.
2.161
The Australian Law Reform Commission has stated that common forms of restrictive practice include detention (locking a person in a room), seclusion (locking a person in a room for a limited period of time), physical restraint (clasping a person’s hands or feet to stop them from moving), mechanical restraint (tying a person to a chair or bed) and chemical restraint (giving a person sedatives).
2.162
Submitters and witnesses presented overwhelming evidence of the inappropriate and indiscriminate use of restrictive practices in place of other interventions, to manage BPSD.
2.163
The Aged Care Commission told the committee of the work the regulators have done to educate the RACF provider sector on restrictive practices, including both physical and chemical restraint:
...we have provided and continue to provide guidance to the sector about our expectations in relation to restrictive practices. In general, we have given clear indications that they are to be used as a last resort and only after substantial consideration of alternative strategies.
When they are used...they are used sparingly for as short a time as possible, and they are subject to oversight.
2.164
The Department submitted information on two Australian Government funded trials aimed at reducing the use of sedative and antipsychotic medications in RACFs. However, evidence presented to the committee highlights the lack of impact the work done by regulators has had on reducing rates of chemical and physical restraint.
2.165
The Office of the Public Advocate Qld submitted that 'the use of restrictive practices to manage the challenging behaviours of people supported by the aged and disability sectors has become a key human rights issue in Australia'. The Office of the Public Advocate Qld outlined that as there is currently no legislative framework to regulate these practices, the 'use of restrictive practices in aged care settings, without legal justification or excuse, is unlawful and amounts to elder abuse'. The Office of the Public Advocate Qld further submitted that staff using restrictive practices do not have the protections of legal immunities and are at risk of criminal prosecution for unlawful deprivation of liberty or assault, or civil claims.
2.166
A significant proportion of submitters raised concerns with the overuse of psychotropic medications in RACF, with some arguing they are 'used not just to treat mental illness, but sometimes as a means of managing challenging behaviour'. Allied Health Professions Australia submitted that the 'use of medication to manage challenging behaviours is a significantly more cost-effective strategy for residential aged care facilities as the cost of medication and GP’s services is borne by Medicare while the use of allied health staff as part of non-pharmacological management of behaviours would need to be funded by the facility'.
2.167
About half of people in aged care, and about 80 per cent of those with dementia are receiving psychotropic medications, with evidence to suggest that in some cases these medications have been prescribed inappropriately. The Chief Medical Officer for the Health Care Commission told the committee that while around 20 per cent of patients who have dementia will benefit from antipsychotics the rates of prescribing were around 80 per cent, showing 'an excess of the use of antipsychotics compared with the potential benefit'.
2.168
RANZCP told the committee that the over-reliance on psychotropic medications can happen for a variety of reasons, with the 'more likely' cause being 'the lack of training on proper management of behavioural disturbances in dementia that all doctors receive'. RANZCP recommended:
This [behavioural management] training really needs to be provided to the people who are responsible [for the] medical management of people in care facilities because, at the moment, all they can do, all they have been taught to do, is prescribe. The analogy is that when all you've got is a hammer everything looks like a nail.
2.169
The Office of the Public Guardian Qld submitted that it has observed chemical restraint being used without formal oversight or consideration of positive behavioural support as an alternative, and has observed it can be used in instances where it may be perceived as a substitute for staff shortages of appropriate training or skills.
2.170
The Health Care Commission told the committee that there has been no improvement in the overuse of antipsychotics since a study they conducted three years ago, which found that in some places antipsychotic use is at 30 per cent 'yet the epidemiology of disease tells you it should only be nine or 10 per cent. We know this is now becoming profoundly concerning, because the medication actually causes more harm than benefit, and that's the message we're trying to get out to the system'.
2.171
The Chief Medical Officer for the Health Care Commission noted that 'the antipsychotics not only sedate the patient but increase the risk of falls and fractures for the patient, increase the risk of the patient developing pneumonia, increase the risk of stroke and increase the chances that the resident will die'.
2.172
On 17 January 2019, the Minister for Senior Australians and Aged Care (Minister), Ken Wyatt, announced draft changes to regulations to strengthen oversight of restrictive practice were 'expected to be released within weeks'. On 30 March 2019, the Minister made a further announcement that he intends to make changes 'next week' in relation to physical and chemical restraint which will apply from 1 July 2019. These changes are discussed in greater detail in chapter three.
Consent to restrictive practice
2.173
Dementia Australia noted that communication with families around psychotropic medications was generally poor, with limited information on what medications a resident may be on, why that medication is being used, and the processes for medication adjustment or review. Dementia Australia further submitted that some individuals have expressed their concern that if consent is not granted, their relative will be sent to hospital as an emergency patient or they will be asked to leave the RACF.
2.174
The Older Persons Advocacy Network made similar comments and told the committee that often families did not understand why people have been put on medications, suggesting that often it could be 'to make life a little easier for the people who are working in the centre'.
2.175
The Health Care Commission also raised concerns with the issue of appropriately seeking consent for using restrictive practices on a person with dementia and told the committee that RACF providers hold responsibility for the prescribed medical treatment for a person with advanced dementia, as the person has no capacity for consent. The Health Care Commission raised further concerns, citing studies which have shown that only six per cent of people on antipsychotic medications have had an appropriate consent procedure.
Committee view
2.176
The concluding committee view in the interim report for this inquiry stated:
The aged care sector appears divided in how it defines the provision of allied health or medical services, and who takes ultimate responsibility for the quality of service provision or the oversight and regulation of that health service.
2.177
The committee remains deeply concerned with the standards of clinical care within RACFs, both day-to-day nursing care as well as other, more specialised clinical services. The committee notes the arguments raised that the lack of access to these clinical services is often due to funding constraints.
2.178
However, the committee also notes that many of these specialized clinical services are in fact higher level nursing practices, for which the RACF provider is paid under the ACFI to deliver. It appears that the internal governance and external regulation of clinical practice is in inverse proportion to the level of clinical speciality. Paradoxically, the more complex the care, the less oversight and regulation.
2.179
The committee is troubled with the high rates of psychotropic medications being used, and the compelling epidemiological evidence which shows this cannot possibly be for purely therapeutic reasons. Despite existing work to reduce rates, restrictive practices are still being used at alarmingly high rates, and where they are done with no clearly defined therapeutic goal and without consent, would constitute abuse and may in fact be a criminal matter. Plainly, work to date has not been successful in reducing restrictive practice to appropriate rates.