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ROYAL COMMISSION: Commissioners turn to solutions for regional aged care

Introducing the aim of this set of Royal Commission into Aged Care Quality and Safety hearings on Monday in Mudgee, New South Wales (NSW), Senior Counsel Assisting Peter Gray QC talked about the focus on aged care in rural, regional and remote areas, and the right for everyone to have the same quality aged care.

Registered Nurse and Diabetes Educator, Ruth Hamilton, says she felt like her and her mother’s wishes weren't being listened to by management of a nursing home. [Source: Aged Care Royal Commission]

“There’s no doubt that rural and remote settings pose special challenges for the delivery of aged care,” says Senior Counsel Assisting Gray.

“Much of this arises from immutable structural aspects of rural and remote living such as widespread dispersion of populations, transportation challenges, geographical isolation from large centres of economic activity and isolation between population catchments, and potentially insufficient population densities to support services that depend on scale to be viable. 

“However, equity of access to quality aged care for Australians who live outside the big cities is a matter of simple fairness.”

The current regional aged care focussed hearings follow the recent release of the Commission’s Interim Report, which Senior Counsel Assisting says begins the new and final chapter of the Aged Care Royal Commission and intends to formulate and test propositions as potential recommendations for the Final Report.

Day one: Poor leadership and management

First witness for the day was 53 year old Registered Nurse and Diabetes Educator, Ruth Hamilton, who described the experience of her mum’s time in residential care in the country.

In the first few years at her new facility, Ms Hamilton’s mother was receiving good care and was happy with the facility.

However, in 2019, Ms Hamilton was having issues with the clinical care her mother was receiving, including continuous breaks in her mother’s gastrostomy tube.

Ms Hamilton told the facility she didn’t want anyone changing her mother’s tube unless she was present to supervise, but this was ignored by the facility.

When she asked the Chief Executive Officer (CEO) of the facility about why she wasn’t notified, the CEO said, “You’re nothing but a bully and no one wants to look after your mother because of you.”

Ms Hamilton says she felt very insignificant and that her and her mother’s wishes were not being listened to.

Commissioner Lynelle Briggs AO asked Ms Hamilton what changes she would like to see to management at residential aged care facilities.

Ms Hamilton says, “Leadership being more open and being supportive and listening to those recommendations and not saying that it won’t be done this way. Just more listening and that coming from that management path that they’re more open and willing to make changes.

“And not the residents or the family feeling that there’s no point saying anything, because a lot of the residents won’t say anything, because they are frightened of the repercussions and that there’s no change anyway.”

Day two: Commissioners test potential recommendations

Day two of the Royal Commission heard from a panel of regional aged care providers, who answered propositions from the Commissioners and whether they would fix problems in the aged care sector.

The panel included General Manager of Branch Operations for the Home & Disability Services at Australian Unity, Dean Chesterman; Head of Home and Community Care Operations Aging at Uniting in New South Wales (NSW) and Australian Capital Territory (ACT), Jaclyn Attridge; and Head of Operations Aged and Community NSW at LiveBetter Community Services, Helen Miller.

The first proposition was about consumer directed care for Home Care Packages and whether that should be replaced by a system of block grants through competitive tenders to address the thin market and scale diseconomies.

Ms Miller says she thinks the principles of consumer directed care are good and does not believe block grants are the answer.

“Obviously, to acknowledge that there are definitely issues in relation to service delivery and funding of those services currently, but I think there are some very good principles that we should maintain,” says Ms Miller.

“And I think that we need to specifically address some of the inequities that occur in the provision of services in rural, regional and remote areas. I don’t believe we should go back to block funding as a totality.”

Ms Miller acknowledges the markets are thin, especially in regional areas, however, that should not take away the capacity for consumers to have choice.

Mr Chesterman adds that there needs to be better recognition of differential costs in delivering services in regional areas compared to metropolitan areas.

Ms Miller continued on, saying that the workforce shortages and skilled workforce shortages need to be addressed because a big barrier in regional areas is access to the right staff.

The second proposition asked was whether consumer directed care for Home Care Packages should be augmented by a provision of flexible funding for providers to deliver a combination of services.

Ms Miller says while that model seems interesting and does have merit, she believes the “devil will be in the detail” in how to administer that model appropriately.

“I think there are some complexities in the detail that would need to be examined. I think some flexible funding is important for rural, regional and remote,” says Ms Miller.

Ms Attridge adds, “I think there absolutely [are] examples where the market just won’t support service delivery, particularly in those services that are more remote that absolutely need intervention. 

“I think a one-size-fits-all approach is the wrong approach and I think the important part about this is asking the community what it is that they think and working with them and the other services that are in the area to look at opportunities or potential solutions that work for those communities because they are just so vastly different.”

One topic touched on was around the fall-out from the interim report and the need for more Home Care Packages.

Even after the announcement from Government that they intend to release more Home Care Packages, Ms Miller says from a client perspective, the news is fantastic, but from an operational perspective, she thought, “Oh my God. Workforce”. When asked what would happen if the waitlist was resolved overnight, Ms Miller says, “We would not be ready. We would need to have time to ensure that we continued to recruit. 

“But, at the end of the day, if we don’t have the workers out there and then it’s not going to be a sustainable option.”

Mr Chesterman added that there needs to be more transparency around when those packages are going to be released so providers can be proactive and ready themselves for future changes.

Day three: Fixing workforce and lacking aged care services in rural areas

Medical and Government officials made up a small discussion panel on day three about ways to improve the small aged care workforce and increase the thin market of aged care services in rural, regional and remote areas.

Deputy Secretary, Health System Strategy and Planning at NSW Ministry of Health, Dr Nigel Lyons, and Director of Rural Health Services in the Western NSW Local Health District, Sharon McKay, gave their opinions on potential Final Report recommendations. 

Dr Lyons believes for regional areas, any solutions to lacking aged care resources will always come down to tailoring services to best suit the needs of the affected community.

“The point I would make is I think we need to be thinking about providing aged care in a way which reflects the needs of communities, and we are a very large and diverse country and the particular needs of rural and regional communities can be different to those in metropolitan settings,” says Dr Lyons. 

“So a market might be available in a large community where there is opportunity for choice. When we move into many of these communities we’ve got major challenges in continuing to provide services due to workforce issues, geography, [and] disparity in population dispersion. 

“All of these factors need to be thought about in the context of how do we provide appropriate care for the people who live in those communities. And I think we need to tailor our approaches to the fact that it is different in different environments.”

Senior Counsel Assisting Gray suggested a proposal for rural and regional scholarship programs to encourage staff with skills to work in the regional aged care sector.

Ms McKay says that this option would be valuable. She says the Rural Health Services medical workforce has suggested paying off the HECS debt of young graduates to encourage them to work rurally.

“I would value it if the Commonwealth was able to come to the party with some sort of incentive,” says Ms McKay.

Another proposition put to the small panel was in respect to the Multi-Purpose Services (MPS) Program and whether that should be expanded into areas with thin markets.

Dr Lyons agrees that would address the issues in areas that do not have many, or any, services, and also provides solutions around access to care and to serve communities that would otherwise not receive access to that care.

The next round of Royal Commission hearings are running from November 11-15, focussing on the aged care operations of selected Approved Providers, and is being hosted in Hobart.


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