Letter to Kate Carnell and Professor Ron Paterson
26 February 2018
A shocking new study reveals aged care home spent an average of $6.08 per resident to provide residents with three meals a day. Michael Gannon, president of the Australian Medical Association, describes this as a “national disgrace”.
In aged care homes, meals are the highlight of a resident’s day. Some aged care homes provide delicious and nutritious meals. Others serve meals that are inedible.
When compared to international food budgets, Australian aged care homes spend 1.4 times less than Canada and 3.8 times less than Norway. When providers skimp on the cost of meals, they are putting residents at risk of malnutrition.
A recent study described at least half the residents in Australian aged care homes as suffering malnutrition. Malnutrition increases risk of falls, pressure injuries and hospital admissions. This not only decreases residents’ quality of life but also increases health care costs.
The importance of older people having a nutritious, well balanced diet is widely acknowledged. Yet it is also important that older people have choice. Recently, a GP told a 94-year-old resident not to eat soft cheeses (her favourite) because it may raise her cholesterol. My mum also loved soft cheeses – and I encouraged her to eat as much as she wanted. Mum had reached an age when she could eat whatever she wanted, irrespective of her cholesterol levels. This included our regular trip to McDonalds for a cheeseburger and a chocolate shake.
In some aged care homes, residents are not given a choice. They are often served meat pies, deep-fried patties and chicken nuggets. Sugary desserts are also common. Given the incidence of diabetes, heart disease and cancer in older people, the high level of sugar and salt in the meals served in some aged care homes is negligent.
Some residents might enjoy helping staff in the kitchen. However, residents are rarely allowed to participate in food preparation. Although older women spent most of their adult lives preparing food for their families, providers claim that food preparation puts residents at risk of injury. Even a simple activity like peeling potatoes is often not allowed because residents (many of whom have peeled potatoes all their adult lives) are at risk of cutting themselves.
Meal times can be chaotic and distressing for those residents who can’t feed themselves. Often their hot meals are served cold. When an aged care home is short staffed, residents may be fed their meals too quickly. This puts residents at risk of choking.
Many aged care homes use outside caterers that deliver meals wrapped in plastic. It is difficult for some older people (e.g. those with arthritis in their hands) to access their meals. Without assistance, these meals may be left untouched. Staff are so busy they may not notice the unwrapped food remains on the meal tray.
There is also concern that residents may not be drinking enough. Mum would be given a full cup of tea and then later a member of staff would take away a full cup of tea. Staff were simply too busy to notice that Mum had eaten the biscuit but not drunk any of the tea.
The Lantern Project fed everyday Australians a typical aged care meal. The food was described as “disgusting”. Some questioned whether it was in fact food. The poor quality of food served in some aged care homes inspired the Maggie Beer Foundation to develop ‘Creating An Appetite For Life’ Education Programs. These programs raise awareness, train staff, managers and chefs to buy and serve fresh produce and make food more palatable.
Residents’ wellbeing depends on aged care homes serving nutritious and delicious meals. Replacing processed food with fresh seasonal produce makes economic sense. Many aged care homes have productive vegetable gardens tended to by those residents with green fingers.
It is beholden on aged care providers to make meal times a happy experience for older Australians living in aged care homes. This will improve the health, happiness and quality of life of residents.
The Age, Michael Bachelard
Sarah Russell’s mother, Joan, died in a nursing home in September 2015. She believes the death was premature.
“When my mother was engaged, she was terrific. When she was alone and not engaged, she’d suffer anxiety … [and] she would get up and walk,” Dr Russell, a public health researcher, said.
Dr Russell gave up work to look after her, but she could not be there at all times, so she attached a note to her mother’s walking frame to warn the personal care assistants at the aged care facility not to leave her walker within reach.
One day, in the dining room after lunch, they did.
“She got up and walked, fell over. She didn’t break her hip, but she did damage her ribs, and six weeks later she was dead. The GP made the connection between the fall and her decline … I think the fall hastened her death.”
by Ian Anderson and Sarah Russell
Another Australia Day has been and gone demonstrating that our history provokes a range of emotional responses – pride, sorrow, happiness, anger and guilt. The large number of non-Indigenous Australians who attended Invasion/Survival Day rallies around Australia suggests guilt is a common emotional response of non-Indigenous Australians when recalling Australia’s colonial treatment of Aboriginal people.
If you accept – as I do – that the Australian frontier was a violent place and many Aboriginal lives were lost in this violence. Also that Aboriginal Australian suffered because of the loss of livelihood, disease and poverty. Then there is much to provoke a sense of guilt. However, guilt prevents constructive dialogue.
Instead I want an honest conversation between Indigenous and non-Indigenous Australians about our shared past and its consequences. I want to have this conversation in ways that enable us all to address the legacy of the past and create a shared future.
Guilt can be a crippling and paralysing emotion. Guilt doesn’t create the basis for reframing our relationships or enabling us to see new alternative futures together. For some, the fear of guilt becomes a reason to avoid thinking about these confronting truths about Australia’s past.
For those Australians who do not have any historical connection to Australian frontier– such as more recent migrants – guilt seems an even less appropriate response.
Hobart Lord Mayor Sue Hickey brought herself to national attention when she raised concerns about The Museum of Old and New Art’s (MONA) proposal for a Truth and Reconciliation Park. MONA has a long-term vision to transform an industrial site into a cultural precinct at Macquarie point. This proposal includes a precinct that acknowledges Tasmania’s colonial conflict with Indigenous people as well as a Tasmanian Aboriginal history centre. It has the potential to become a national building project with an innovative cultural space that creates new ways for Australians of all backgrounds to reconcile our colonial past.
Sue Hickey said a Truth and Reconciliation Park would create “a guilt ridden” place adding that she “didn’t kill Aborigines”. She received public opprobrium for her comments, particularly from Indigenous Australians. Although her initial comments were clumsy and caused offence, subsequent discussions between Sue Hickey and Tasmania’s Palawa (Aboriginal) were positive. However, the incident illustrates how the fear of guilt can get in the way of conversations about our colonial past.
I am not promoting a naïve dewy-eyed nationalism that glosses over the confronting aspects of our history. If we are going to have a shared future, we need to collectively remember our colonial history. But there may be more productive ways to set the tone for our engagement with our colonial past.
A dialogue about our colonial history underpinned by generosity, empathy, respect and compassion has greater potential for constructive engagement with our colonial history and its legacy. This approach may allow us to acknowledge past suffering whilst at the same time opening up new ways for us to relate to each other and build a shared future. This is a future in which we all belong but in different ways.
Every year we have difficult conversations about the problems associated with choice of the 26th of January to celebrate our Australian nationhood. This year was no different. Australia day honours, BBQs, citizenship ceremonies and invasion day/survival day marches were all held concurrently. Once again, Australia Day – a national day that should bring Indigenous and non-Indigenous together – divided our nation.
A poll published in the Guardian found most Indigenous Australians want the date changed. 26 January is the anniversary of the date in which the First Fleet raised the Union Jack in Sydney Cover in 1788. It is a date that by virtue of its historical symbolism causes pain to Indigenous Australians.
26 January became a public holiday uniformly across all Australian states only in 1994. For many Indigenous Australians it is symbolic of the act of dispossession. Yet we seem unable to have a frank and honest conversation about changing the date. Being dismissive and responding that this is a silly conversation – or that it is “political correctness gone mad” – is not a generous way to bring all Australians into a celebration of our shared collective future. A generous approach to dialogue based on empathy, respect and compassion would seek to find a date to celebrate our nationhood that is inclusive of all Australians.
We need a way to talk about our past that is honest that acknowledges harm both intended and not intended to Indigenous Australians. Perhaps this would be more productive if we were able to move from one based on guilt to one based on emotional engagement that is enabling. That might require us all to shift our approach to each other and acknowledge the multiple cultural traditions. Whoever we are – Indigenous, descendants of settler Australians, migrants or refugees – we all have a stake in our nations future.
Residential aged care in Australia is big business. The Aged Care Financing Authority estimates the residential aged care sector requires $31 billion of investment over the next decade. To attract investors, the Productivity Commission recommends a competitive market with reduced regulation. Private equity firms, new foreign investors, and superannuation and property real estate investment trusts are entering the residential aged care market in large numbers.
The ‘Living longer living better’ aged care reforms have decreased regulation and introduced a consumer-driven market based system. The irony of this move towards a free market system is that providers rely on government subsidies. The government pays approved providers a ‘residential care subsidy’ for each resident living in an aged care home. The amount for each resident is calculated using the Aged Care Funding Instrument (ACFI). ACFI is used to pay subsidies based on each resident’s level of need. It has three funding categories: Activities of Daily Living, Behaviour and Complex Health Care. Funding in each of these domains is provided at four levels: high, medium, low or zero.
ACFI provides a financial incentive to classify residents as requiring a higher level of care. The provider receives additional subsidies when a resident is reclassified as requiring a higher level of care. However, staff levels rarely change nor are extra services provided to the resident. Where do our taxes go?
Under the current arrangements, the providers do their own assessments for government subsidies. Although politicians and peak bodies may claim that the overwhelming majority of providers are doing the right thing, the ACFI Monthly monitoring reports do not support this claim. It has been reported that one-in-eight of 20,000 ACFI claims audited last year (2014-15) were deemed to be incorrect. This figure is already tracking higher at one-in-seven in 2015-16. The ACFI Expenditure Working Group has been formed to understand the causes of recent growth in residential aged care subsidies.
Michael Pascoe asked: “Where’s the dividing line between systemic fraud and “innocent mistakes” in the aged care sector? It’s somewhere in the hundreds of millions of dollars very-much-for-profit aged care providers have been ripping out of the system by exploiting a flawed funding model – a model that encourages exaggerating care needs and discourages improving the health and independence of individuals”.
The changes to the Aged Care Funding Instrument (ACFI) announced in the federal budget have caused some private providers to worry about their profits. In a letter to managers of aged care homes, Optimum Healthcare Australia estimates the changes to ACFI will result in an average 80-bed aged care home losing $439,000 per year in government subsidies.
Not surprisingly, the peak body representing private providers is asking the government to reverse its decision. Leading Aged Services Australia has launched a campaign: ‘Reverse the Cuts – Fund the Care Australian Seniors Need and Deserve’. In response, Aged Care Matters has begun a reverse campaign: “Cut the greed: Provide the care Australians fund”. When a resident is classified as requiring higher needs, additional resources should be directed towards the resident with higher needs. Aged Care Matters also calls on all providers to stop exaggerating residents’ care needs.
Optimum Healthcare Australia recommends aged care homes re-appraise residents before the January 2017 to ensure funding is “grandfathered”. They recommend residents’ care needs are reassessed “to determine what care they actually need, not just what is reported by carers.” With their assistance, providers will “experience minimal financial impact from the [ACFI] changes”.
Some ACFI coordinators and ACFI consultants describe their role as “generating income for the providers”. An ACFI coordinator for an aged care home with 160 beds told Aged Care Matters that he is “highly stressed as the provider expects the ACFI rate for all residents to be at least $204 per day”. He described the provider for whom he works as “cooking the books” to maximise funding.
ACFI consultants must not only stop exaggerating residents’ care needs, they must also stop reclassifying residents with an illness and care needs that they do not have. Recently, an aged care home falsely claimed a resident had Parkinson’s Disease, and related health deficits, for which the provider claimed a subsidy under ACFI. When his daughter complained to ACFI Compliance Section, she was told that the appraisers “must be able to trust the word of the health care professionals at the aged care facility”.
ACFI is built on an honesty system. In an era of fraudulent behaviour in both pink batts and private colleges, it is clear that profit-based systems that rely on government subsidies cannot rely on honesty. The funding of aged care homes require transparency, scrutiny and accountability. We must all know how the providers spend our taxes.
When a resident in an aged care home is reclassified as requiring a higher level of care, the extra funding should be used to employ more staff or to introduce services such as strength training, music or lifestyle programs that would improve residents’ quality of life. Their care must not be traded on the market like any other commodity.
Dr Sarah Russell is the Principal Researcher at Research Matters and a former Registered Nurse. She is a foundation member of Aged Care Matters.
Published in Online Opinion