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Standing Committee on Health, Aged Care and Sport
26/04/2018
Quality of care in residential aged-care facilities in Australia

HARRINGTON, Ms Anna, Policy Officer, Aged and Disability Advocacy Australia, Older Persons Advocacy Network

ROWE, Mr Geoff, Chief Executive Officer, Aged and Disability Advocacy Australia, Older Persons Advocacy Network

[10:01]

CHAIR: Thank you very much for joining us today. I'll just go through the formalities, which you've probably already heard. Firstly, do you have any objection to being recorded by media if they happen to be present today?

Mr Rowe : No.

CHAIR: I need to remind you that these are formal proceedings of the parliament. The giving of false or misleading matter and in some circumstances can be regarded as a contempt of parliament. Today's proceedings will be recorded by Hansard and attract parliamentary privilege. Thank you for your written submission. I invite you to make some opening remarks before we move on to questions.

Mr Rowe : Certainly I'd appreciate that, thank you. I'd like to open my remarks with an acknowledgement of the traditional owners of the land on which we meet today and pay my respects to their elders past, present and emerging.

I'm wearing two hats, with one for the Older Persons Advocacy Network. OPAN is funded by the Department of Health under the National Aged Care Advocacy Program to deliver individual advocacy support, information, education to consumers and education to staff in Commonwealth funded aged-care services across residential care, home care and the Commonwealth Home Support Program. We also provide that support to people who are seeking to access Commonwealth aged care or their families or carers. OPAN operates from a rights base to ensure that the voices of consumers are heard.

At the moment OPAN has a service delivery organisation in each state and territory across Australia. There are nine service delivery organisations. ADA Australia is the service delivery organisation for Queensland. ADA is an organisation that's been providing aged-care advocacy support, amongst other services, for the last 25 years. We have regional offices across Queensland. We have dedicated Indigenous staff and CALD staff, and have previously had an LGBTI advocate. We also have a guardianship team that works with people with impaired capacity and supports them with their dealings around enduring power of attorney, advance health directives and matters where their decision-making is being questioned. We support people through the QCAP process. We also host the Aboriginal and Torres Strait Islander Disability Network of Queensland. We provide advocacy support to the Queensland Community Care program for people under the age of 65. So OPAN and ADA are well placed to support aged-care consumers.

A point I'd make early on is that, while OPAN and ADA as organisations do significant work in the aged-care sector, the annual budget under NACAP is around $8 million a year. If you think about there being about 1.2 million or 1.3 million users of aged-care services, you see that perhaps we can buy everyone a cup of tea. There's not a lot of time to actually spend with individuals.

One of the important roles that we have is to provide education to consumers, and that education is about their rights but also their responsibilities. We also provide education around consumer rights to workers in aged care, particularly residential aged care. OPAN is very encouraged, on one hand, but also distressed by what it sees in respect of quality across the aged-care sector. As you no doubt heard from the nurses union before, quality is a very variable thing across the aged-care sector. We see some fabulous practice and we see some very poor practice. We outlined in our submission that we were concerned that mistreatment of older people in residential aged care is grossly underreported, and I guess I'd like to repeat that. Even though we have come to be almost immune to the stories in the media each week about the horrid things that are happening in aged care, I don't think we've seen all of it. There is a significant fear of retribution, be that real or otherwise, as well as a lack of understanding of individuals' rights.

When we start talking about quality and quality accreditation, we're really concerned to see that the focus be on compliance rather than on continuous improvement. No doubt you've heard lots of stories, and we can tell you lots of stories, about new crockery being put out for the day of the audit, about difficult residents being taken out on a day trip, about staffing being significantly higher et cetera. My history has been one of working in other sectors as well as aged care, and elsewhere we've seen it picked up as continuous improvement and an opportunity to improve services, and sadly we don't see that. We see a culture within aged care of older people being required to relinquish their rights when checking into residential aged care. We also see that there is a growing requirement that people relinquish their capacity as they enter into aged care. It's almost like you've walked through the doors and any capacity you have had in relation to decision-making is now gone.

Going back to the education comment: at the moment we're funded to provide 1,400 education sessions per year across Australia as OPAN. When you know the number of residential aged-care facilities you will realise that that is only a fraction of the number of aged-care facilities that exist across the country. While there is perhaps no formal research, we've certainly seen a direct correlation between the services that manage to make the front page of the paper and those that have not been willing to have OPAN advocates in to talk about people's rights and their responsibilities. We get quite frustrated that there isn't a formal requirement that legislates for, or even requires as part of the quality process, aged-care advocacy to be known and used and education to be welcomed and invited. You won't see them in this submission—that was a previous submission—but there are certainly some examples where we've been invited in a month before the certification process goes in, so it's a box that can be ticked rather than a commitment to people understanding their rights.

I think there's an opportunity within the aged-care accreditation process—and I'm a bit disturbed that I only thought about this earlier this morning. While the quality agency talks to various stakeholders about the quality of care provided within aged care, there's no formal mechanism whereby they talk to advocates or NACAP funded services about what their experience with consumers—not only consumers but staff—from the facility has been.

CHAIR: As part of the individual accreditation process?

Mr Rowe : As part of the individual accreditation process, I think, it would be really interesting. Anna can certainly talk to some examples that we've put in a submission in relation to the quality accreditation process, but we've seen organisations that get 44 out of 44, tick the boxes and say, 'We've done everything right'. We've got a very long list of concerns expressed by residents of those facilities that aren't being heard in the quality process. Often those people get to the point where things have got so bad that they actually leave the facility and go somewhere else and there's no real measure of that. I think there is value to be gained with the quality agency, or the auditor, who is talking to an advocate to say, without disclosing any of the privacy issues, what number of calls do you get? What're the issues you're getting? Have you been able to go and provide education within that facility?

I'd like to echo the comments made by the nurses' union. There have been numerous inquiries with lots of strong recommendations. The ALRC report, the Carnell Paterson review and many more. OPAN, ADA and others have contributed to those. We believe it's a time for action and a time for leadership. We welcome the announcement of the new aged care commission but there's more that needs to occur. Perhaps if leaderships isn't given by government in terms of the reform I hold some hope that the changing face of the aged-care sector or the aged-care users will lead to that reform.

When I started in my current role, about four years ago, and talked to the advocates who have been working for many years about the current users of aged care they described them as, 'The grateful generation'. They are a cohort of people who are grateful for what they get, they're reluctant to complain and they accept things that others wouldn't necessarily. We know that the baby boomer generation who is now on its way and is knocking on the door—

CHAIR: Never grateful—

Mr Rowe : No-one's ever described them as grateful, absolutely. You've taken my line. I think that is a reality. We're seeing the tips of that in home care based services. I think residential aged care absolutely needs reform. I'll leave it there and see if you have questions to our submission.

CHAIR: I'm going to ask a couple of questions to play devil's advocate. How do you know there's underreporting? I note in your submission that you refer to the fact that there's evidence of that, that so many of the complaints come from family rather than residents themselves. There could be another reason for that. I think about the aged-care facility I was at two days ago, and if I looked around the room of 50 residents I could understand why they may not be making the complaints themselves, because they're in a high state of dementia et cetera. How can you empirically test—

Mr Rowe : How can I make that statement.

CHAIR: under reporting?

Mr Rowe : I'll make a comment and then flick to Anna and hope she's got a good answer. Certainly one of the things that we see is—

CHAIR: It sounds like we should flick to Anna straightaway!

Mr Rowe : As I said, part of our role is to provide education to residents of aged care. Invariably what happens when we provide education to residents is that at the end of the education session one, two or more will say, 'Can I have a chat with you please? I wasn't aware that there's an avenue for raising a concern. I'm really fearful. I need support if I'm going to raise that concern.' That's absolutely a regular thing that we see. If we're not there, who is there? I know we've got the aged care complaints commissioner but, again, people have to know about the commissioner and need to get out there. When we talk about the commissioner one of my frustrations is that while there are some really good things that they do they're based within a CBD or based around a phone. One of the things that advocates offer is that they actually get out and into aged-care services, and whether we talk about Queensland, Western Australia or South Australia not everyone lives in the city. It's really important, talking to older people, that we actually get out and talk to them face to face.

Ms Harrington : I agree with what Geoff said and I'll build on what QNMU said before around workforce and supporting people within the workforce to be able to raise issues without the fear of losing their job. That's definitely a very important factor. We certainly hear of a lot of staff who have great concerns but don't want to say anything.

Also, I think there have been some recommendations around the reportable assault scheme being replaced with the serious incidents scheme. I think, from the recent announcement by the minister, that that's one of the areas that will be looked at in the not too distant future. That's really encouraging. I think the scope of the reportable assault scheme at the moment is so limited, and the new scope under the serious incidents scheme broadens it out to include neglect and financial abuse and all those sorts of things that are probably not being picked up on now. Also, people perhaps are not feeling protected in raising those sorts of assaults as well.

Mr Rowe : I have an additional comment—sorry, if I can just interrupt. One of the things we certainly frequently hear is that family members, when they start to raise concerns around issues, are excluded from facilities. So, again, there's a culture of: 'Don't raise it. I can no longer have my son or daughter visit because they've complained about the service.' Retribution is real.

CHAIR: I thought you made an interesting point about the involvement of advocates in the accreditation process. In terms of the advocacy network, would it be fair to describe you as the peak national manifestation of advocates in the sector?

Mr Rowe : The evolution of advocacy, aged-care advocacy particularly, has been: historically the Department of Health has funded a service provider in each state and territory, with the exception of the Northern Territory, where they've funded two organisations. In the last tender round, which was about 16 months ago, the Commonwealth expressed an interest in funding one agency so that they could provide a nationally consistent advocacy service across the country. So, we're not quite a peak body. OPAN, I guess, is the single aged-care advocacy provider.

CHAIR: But what I'm getting at is: in terms of practicalities, the accreditation agency, or whatever it morphs into, would simply approach you and say, 'We're doing Smithtown aged-care facility today. What do your records show?'

Mr Rowe : Yes—that's very easy.

CHAIR: I suppose, looking at it the other way, if you're advocating on behalf of residents and you're detecting problems, wouldn't you be automatically reporting that to the agency and the department in any case?

Mr Rowe : Yes and no. I think there's some variability across Australia in terms of the advocacy agencies, and that reflects history and historical funding. ADA is actually the largest provider of aged-care advocacy services. We have significant resources compared to others. Some of the smaller states and territories may have only one or 1½ advocates, so they're really stretched just responding to calls.

CHAIR: Where—which states—are you the primary advocacy group?

Mr Rowe : I'm not quite sure of the question.

CHAIR: Which states does the ADA not operate in?

Mr Rowe : We only operate in Queensland—despite the name. We work in disability, and disability ignores state and territory boundaries a bit more so. You've got Seniors Rights Service in New South Wales; elder rights in Tasmania; ARAS in South Australia, which I believe met with the committee a couple of months ago; and Advocare in WA et cetera, et cetera. We are trying to, and I think in Queensland we do, have a good relationship with the department, with the Aged Care Complaints Commissioner and also with the quality agency. It's one where we try and work together. That's more about us initiating and trying to develop those relationships. Again, I come back to the smaller jurisdictions: their capacity to take an hour, 1¼ hours, or whatever it is, to go and hunt the various players down is a lot less than what ADA's is.

But, in having a formal approach around each service, are we to go and talk to the department every time we get a complaint about a service? Last year, ADA provided advocacy and information services to 3,000 people across Queensland, so would I make 3,000 visits to the quality agency? It would become a nonsense. The complaints range from really minor things to—

CHAIR: Yes, but presumably you're seeing a pattern.

Mr Rowe : We try to raise significant stuff with the department, but there isn't anything proactive. We don't know when the audits are.

CHAIR: I understand. My final question is a broad one, so it might be difficult to answer. Inquiries like this tend to focus intrinsically on where the problems are. In your opening remarks you alluded to there being some exceptionally good operators and some that are not so good. How would you typify the sector overall? You sit through these types of inquiries and vow never to go anywhere near an aged-care facility. On balance would you say the vast bulk of aged-care facilities are providing excellent services, or would that be overly optimistic?

Mr Rowe : I suspect I'd like to take that on notice, but I don't know that I want to do that either!

Ms Harrington : As an advocacy organisation, we are often brought in when there is a problem.

CHAIR: So you're seeing the worst.

Ms Harrington : Yes.

CHAIR: People aren't ringing you to say, 'My facility is fantastic.'

Ms Harrington : That's right.

Mr Rowe : There is no correlation between how beautiful a facility is and the quality of care. I have a friend who has gone into work around brokering in residential aged care after many years working in the financial services area. He said to me, 'Some aged-care providers spell care C-A-S-H.' The focus is on money, it's not on people. I hear staff say, 'I never want to go into residential aged care.' Maybe we have a warped or perverted view of the world, given the area in which we've worked. There are some excellent facilities. A potential user of aged care has to do their homework and look beyond the facade.

CHAIR: But would it be fair to say the successive complaints you're getting are evenly spread, or are there some parts of the sector or some facilities in the sector which—

Mr Rowe : We hear more about some facilities. We hear wonderful things about some facilities. As Anna commented, perhaps the strength of a service is in how they respond to those complaints and how welcoming they are—that their residents understand that there are complaints mechanisms and they are able to raise concerns without retribution. Some services welcome and work very closely with people to try to resolve them. When we work with people around issues we attempt to give them the skills and the confidence so that next time they have a concern they can raise that directly rather than having to knock on our door, because they know that there won't be retribution, but that's not always the case.

Mr LAMING: With the success of the My School website, has there been some argument for more consumer feedback on quality available on a public platform?

Ms Harrington : I would say from doing advocacy work that people are looking for that. They ask us as advocates for opinions on different facilities, which we can't give, to avoid any conflict of interest. From the advocacy perspective it comes up a lot. People want to know how to choose a place, how to know they're a good service. Having somewhere where that type of information is available would be valuable.

Mr LAMING: Over the cycle, seeing the nature of complaints and the way the facility responds to those complaints would provide some additional public information about the quality of care at least in an anecdotal sense, because you would see what people in the facility, residents and their families are saying about the quality of care, whereas in my electorate I've absolutely no idea about the quality of care. As you said, it has nothing to do with what the facility looks like, so where else can I get this information from as a citizen?

Mr Rowe : The Aged Care Quality Agency has recently introduced a consumer report, which is available on the website 'post an audit', which gives a bit of a snapshot of that. My word of warning is we are seeing more and more that people enter aged care at a time of crisis. I heard earlier your discussion about how aged care is referring residents back into the health system. A lot of people are being pushed out of hospital beds and into residential aged care who may have been able to return home with more planning and support, but it's about freeing up the bed, and that's deeply concerning at both ends. If there were an easy spot for people to go to find out what's on offer, rather than just the organisation's website, that could only add value. Information is power, so the more information you give people, the more opportunities they have. A lot of families are involved when that decision comes. Will my parents use a website when they're looking at residential aged care? Absolutely not: they'll talk to me or my sisters. I'm not living where they are, so I don't have that local knowledge, but I'd probably access that if it were available

Mr LAMING: Without straying to that very important issue of possible discharge and access to aged-care facilities, as opposed to being home if we could manage the social circumstances, the separate issue is that of whether long-term residents and their families are receiving care they're happy and satisfied with. Moving is quite hard. It's not easy to say, 'It's not working out here for me; I'm going to move.' It's a pretty rare thing; I'd like to know how often it happens, but in short, are you prepared to say the recommendation from this report should be that there be a clearing house where we can publicly see in real time the nature of complaints and, more importantly, the ways facilities respond to those complaints? They could be vexatious and driven by emotion, as you pointed out, but how you deal with a complaint is as important as the actual complaint itself. Do you think customers want more information about how people feel the services are being delivered inside a facility or not?

Ms Harrington : The new consumer reporting that has come out through the Aged Care Quality Agency is great at giving that type of information. I think people are seeking that, but it's important that the processes that lead up to that report are looked at. You look at their current processes for consumers to participate in providing feedback in accreditation, and the service providers quite often are the ones responsible for informing the residents that an accreditation visit is coming up. In some cases we hear of cherrypicking people to be involved—the ones that aren't going to raise too many issues when talking to the accreditation agency. A lot more work needs to be done around those sorts of things, ensuring the consumers inform that type of information—

Mr LAMING: The best thing is to allow consumers to directly put that information in real time into a clearing house that everyone can see. I respect your saying the current quality report is fine, but it's prepared by agents on behalf of two parties, and they'll be fearful of hearing what customers think in real time.

CHAIR: TripAdvisor for aged care.

Mr LAMING: Yes, five-star rating, anything and everything in real time.

Mr Rowe : It's a double-edged sword. It brings to mind a recent situation where one of our advocates supported a woman with dementia who wanted to do something different from what her son was doing. Her son had an extensive criminal history that we asked QCAT to check out. He was very angry with that result. Our staff were named and shamed on a website, Google reviews and Facebook pages around the country. What did our person do? Absolutely the right thing. What was the outcome? The outcome was a positive one for the consumer. She didn't have all of her resources stolen by her son. Those sorts of issues concern me. Not everyone uses those, particularly when you are able to put the information in yourself. Moderation would be required and probably a lot of it. At the same time we need more information. That sort of website also should give people a simple guide to what questions you should ask and who you should talk to when looking at aged care. You can talk to other people using that service. Those websites are great in places like Brisbane where you have lots of choice. If you're in Cunnamulla—I don't know what the situation is this there, so I probably shouldn't use that—if you're in a rural or regional town, you might have one choice, although we find in those communities, because they're small communities, people know each other and talk, and the sorts of issues we're seeing across the front page of the paper are less common in those communities, so it potentially could work.

Mr ZAPPIA: Do you have confidence in the accreditation agencies?

Mr Rowe : Some of our previous submissions have raised that. My opening comment was that the focus is too much on compliance and not enough on quality improvement. I think the changes that are being—

Mr ZAPPIA: I understand that, but it doesn't answer my question.

Mr Rowe : I understand I'm not answering your question. I think—

CHAIR: Why aren't you answering his question?

Mr Rowe : Perhaps because I don't have full confidence. I think there are—

Mr ZAPPIA: Maybe that's your answer—that you don't have full confidence.

Mr Rowe : Yes, maybe I'll leave it at that.

Mr ZAPPIA: That's reasonable. I was going to pursue the issue of some kind of reporting system, which it seems we don't really have but would be very useful.

CHAIR: I would make the observation, having worked in this area in my previous life, that the tourism sector had enormous concerns about TripAdvisor when it first came on the scene. There were reports of businesses destroyed by unfair bad reviews. It has matured into a product that has more respect. It has problems, but the role of consumers in providing that clearing house of experience can be quite a valuable one.

Thank you very much for your participation today. That has been very helpful. You will be provided with a Hansard transcript of today's proceedings. If there are any corrections, please contact the committee secretariat. I'm not sure whether you took any information on notice, but if you did, we will let you know and confirm that. Hopefully this will be the last inquiry you appear before for some time.

Proceedings suspended from 10:31 to 10 : 46