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

GONSKI, Dr Peter Neil, New South Wales Division Committee, Australian and New Zealand Society for Geriatric Medicine Inc.

REYES, Dr Patricia, Secretary, New South Wales Division Committee, Australian and New Zealand Society for Geriatric Medicine Inc.

CHAIR: Thank you very much, Dr Gonski and Dr Reyes, for joining us this morning. Do you have any objection to being recorded by the media during your evidence?

Dr Gonski : No, that's fine.

CHAIR: Before we get underway, I'm required to remind you that today's evidence and hearing are considered formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and may be regarded as a contempt of the parliament. The evidence given today will be recorded by Hansard and attracts parliamentary privilege. Before we move onto questions, would either of you like to make an opening statement?

Dr Gonski : I'd like to, firstly, thank you for the opportunity for us to be involved in this. I'd just mention that the Australian and New Zealand Society for Geriatric Medicine is the national body that represents a whole group of geriatricians across Australia.

Geriatricians are physicians who look after older people, particularly people with aged-care issues, including multiple chronic medical problems, dementia, deteriorating mobility and falls. Medical involvement spans acute care—often in acute hospitals, but not necessarily—subacute care, chronic care, rehabilitation and palliative care, so we really look after the person in all aspects of their deteriorating illnesses. Geriatricians have been involved in aged-care facilities for many years, and this has significantly increased over the last few years. We not only look after people in hospital, but we actually go out and see residents of aged-care facilities who have chronic problems, including dementia, pain et cetera, and we look after them. We also now have flying squads that go out urgently to see people who are deteriorating, so, instead of a resident in an aged-care facility deteriorating and being put in an ambulance and going to an emergency department, we now have a lot of teams that can urgently go out and see these people and assess them, and, through this mechanism, we've been able to reduce their hospitalisation by 90 per cent.

We are very active in nursing homes. From a clinical point of view, governance and accreditation are much less part of what we've been doing. Some of us are on the boards of aged-care facilities, but that is a fairly rare situation. We are advocates for older people and people with aged-care problems, as there are some younger ones who actually have dementia whom we also look after, and, overall, we are great advocates for them. We try and look after them clinically and we're happy to be very involved in both the safety and the quality of care in these facilities.

Mr GEORGANAS: In terms of geriatric care—obviously, a population like Australia is ageing at a very rapid pace at the moment—with issues like dementia and a whole range of other issues relating to older age, are we, as governments, in your view, dealing with older Australians and their health and other issues in a manner that looks towards the future? And how will we deal with the increasingly growing numbers of people with dementia and a whole range of other things that are related to older age, palliative care and all those other things, like having dementia units and geriatric units around the country? A broad view would be good for the committee.

Dr Reyes : I would say, to an extent, yes. There have been plenty of initiatives from the government, like integrated care in particular. But in my experience of being at the forefront of it, and having experience in both acute geriatric medicine in the hospital as well as community medicine, there is still a level of fragmentation in integrated care. It's good in concept. The New South Wales policy on integrated care was a very well written document, but whether or not it's happening in practice is where we're failing a little bit, I think, because there are funding models for different services, but whether or not they work efficiently in a streamlined process is the thing in question.

Dr Gonski : We really do try and keep people in the community rather than in aged-care facilities. It's an interesting situation; people have been assessed as requiring higher and higher care but they're not able to access that care. The assessment and what's actually provided, as far as packages and things like that are concerned, are just not at a reasonable level.

Mr GEORGANAS: Is that your experience while you're out—

Dr Gonski : Totally. The levels of care that are required by a person are assessed as being between 1 and 4. A lot of people are being assessed at 3 and 4, but only packages for 1 and 2 are able to be used because there are just too many people at 3 and 4. So the government really needs to be looking at processes to increase that care, and then we will be able to keep people out of aged-care facilities and keep them in their own homes, which is where they want to be.

Mr GEORGANAS: In your experience, you'd say that people who perhaps require a certain level of care are not receiving care.

Dr Gonski : Correct.

Mr GEORGANAS: Would that then put that person at risk of being hospitalised into an aged-care facility?

Dr Gonski : Our experience is that, if people can get advocate care at home, that will reduce hospitalisation and admission to an aged-care facility.

Mr GEORGANAS: So if someone's been assessed for a level 4 and they're only receiving a level 2, the risk would be quite high that they will end up in hospital or in an aged-care facility.

Dr Gonski : Correct.

Mr GEORGANAS: The other point I wanted to touch on was the physical restraints, whether they be chemical et cetera. You say there's no evidence of their efficiency or safety at all. Would you like to elaborate and tell us a bit about how you came to that view?

Dr Gonski : For us, the word restraints is a no-no. We very much do not want restraints because the safety of them is extremely poor, and that's been over many years. Occasionally—and it is very occasionally—people do need chemical or physical restraints, but on the whole there should be other ways of managing people. For example, if we have a patient or a resident who has severe dementia who wanders all the time, the place to look after them is in a place where he or she can wander all the time—not restrain them in any way. That's where it's so important to match people's needs with what they are provided with—whether it is environment, nursing care et cetera.

Mr GEORGANAS: In a situation where someone does want to wander but they're legs just won't carry them—so there's a risk of injury—would that be—

Dr Gonski : That's not a reason to use a restraint. Basically, they need to be made comfortable as much as possible. They need to have staffing that will keep an eye on them, because that is actually the best way to reduce the risk of falls. They need to be in an environment where there is a bit of diversional therapy so that they're thinking about other things—that they don't want to go wander and get out of the place. There are a lot of things one can do to reduce the use of restraints.

Mr GEORGANAS: One of my last questions is a broad outline of the main challenges that are faced by geriatric medical professionals in your position and the people who you represent treating aged-care recipients. What should be the priority for reform in this area?

Dr Reyes : As far as the society's concerned, we feel that the priority should be partly on the recognition of this cohort of patients who have a variety of chronic illnesses that impact on their ability to function or mobilise. The identification of these very complex patient needs is what we're driving as a specialty that has been unrecognised—for example, the experience with Oakden, which was run mainly by psychogeriatricians. Some of our colleagues in geriatric medicine actually tried to get in and help them identify the deteriorating patient. It's that identification of the deteriorating patient, whether they're in the community or a residential aged-care facility.

It's a fine balancing act that we do. We don't see the patient as one problem at a time, which tends to be the issue with our other medical colleagues. We tend to look at the patient as a whole and look at every single medical, social or environmental issue that needs to be addressed. Where we have a role in this is actually providing that balance. One of the other key things is frequent assessment. When you talked about chemical restraints, it's not that it's a blanket, 'No, nobody should have chemical restraints.' Sometimes you will have to balance harm to the patient and to the other residents with the need for chemical restraints. Where we find we can offer something as a specialty is finding that right balance of medications and nonpharmacologic interventions to help optimise that patient's function and quality of life.

Mr GEORGANAS: Would you say that hospitals and facilities are overusing chemical restraints? Perhaps not overusing—it's an easy option, an easy way out.

Dr Reyes : That used to be the case. There is now a very big push in terms of education of medical specialties, not just in geriatrics but also psychogeriatrics and general practice, against the use of chemical restraints. The junior trainees will know not to use them as first line. It's always nonpharmacological therapy. Even in the aged-care facilities, at least in my experience here in Sydney, there is a big push for education of aged-care facilities not to use that first line. That thought that nursing homes just put patients on medications and don't review it has not been my experience.

Dr Gonski : I think it is really important that apart from proper assessment, recurrent assessment, which is absolutely critical, there needs to be the right environment and there needs to be a very person-centred management plan. And if you can do that you can often have no medication, particularly for behaviour, or maybe minimal medication. It's important to look at individuals, but it requires staffing and it requires good staff who know what they're doing, and then it requires an environment where people can be looked after properly.

Mr GEORGANAS: When you say staffing, and then good staffing, we're talking about ratio numbers, staffing in hospitals and facilities—

Dr Gonski : It's ratio, quality and educated people who know what they're doing.

Mr GEORGANAS: Is that the case currently?

Dr Gonski : I think it's a mixed bag. I think it's like everything—there's good and bad. There are definitely, unfortunately, still some places where they don't do it particularly well. In many of the hospitals we've opened what we call behaviour units where people who've got behaviour problems, which could be acute deterioration, like delirium, or chronic deterioration, due to dementia, where they can't be managed in other places at this moment in time. They're purely for behavioural problems. Our nursing staff and allied health staff know how to manage these people, and we can minimise the amount of medication and minimise the amount of adverse effects. I don't want all dementia sufferers to go through a unit like that, but we're talking about the ones with the worst behaviours.

At least we do a full assessment. We manage them. We sometimes have them on medication, or maybe not. Then they are discharged, often to residential aged-care facilities, hopefully with a whole plan of how to manage these people—even to the extent of what they like, what they don't like, when they want to shower and when they don't want to shower. All these things are incredibly important and can minimise the use of pharmacological treatment.

Dr FREELANDER: Thanks for coming today. It's good to have you. My electorate is out of south-western Sydney. It seems to me, and I'm getting lots of inquiries, that the waiting lists for aged-care assessments are getting longer and longer. Most of the people in some of the aged-care facilities in my electorate never see a geriatrician—never, ever—and certainly don't get frequent assessments. It's very difficult for families to access appropriate assessment and ongoing management. As far as I'm aware, there's no dementia-specific unit in my electorate either. Our local public hospital has many people taking up beds for prolonged periods of time trying to get into aged-care facilities. My feeling is that things are getting worse, not better. Would you like to comment on that?

Dr Gonski : I think there's a big problem if all that's happening. It's certainly not happening in a lot of other districts. All of those things that you mentioned are incredibly relevant and they need to be turned around. The way to do that is by basically increasing the knowledge of everybody and making sure that there are people around to assess these people. It's really important that the aged-care assessment teams are very much aware of what's going on.

With regard to waiting lists for aged-care assessments, this has been increased a lot in the last two years with the changes to My Aged Care. It has improved more recently but there was about an 18-month period where things were very, very slow. The ACAT, Aged Care Assessment Teams, are assessing a lot of people for a lot of needs. It's not just to go into aged-care facilities; it' for community care and for other things as well. I take your point completely and I agree with you that in some areas the care for the aged is not timely and it needs to be ramped up a lot.

Dr Reyes : I think there are two components to your question, the first being the training of more geriatric medicine specialists. Historically, our specialty hasn't been the most popular with medical graduates but I'm glad to report that that's changing. Last year was the first time we were oversubscribed in recruiting as a specialty. So that area is improving, but I think there needs to be more work done in attracting medical graduates to undertake geriatric medicine as a specialty, because we're the specialty that's actually growing in the number of patients about to need geriatric medicine as a specialty.

The second component to that is the aged-care assessments. As geriatric specialists, we're not part of that entry process into aged care. If you put us into that equation, it only prolongs that approval process to get into an aged-care facility. But Professor Gonski has already answered that question with the aged-care assessments in My Aged Care. We did find a lot of teething problems with My Aged Care. It actually delayed referrals to the specific services. For example, there used to be a one- to two-week waiting list to get seen by community nurses, but that ended up being three months. In my local area, they've actually closed their books because the referral list has grown ridiculously long.

Dr FREELANDER: Do you think waiting times are getting longer?

Dr Reyes : For certain specialty services, yes.

Dr FREELANDER: One of the concerns that many families have if they're worried about the care their relative is getting is who they contact with their concerns and how they get reviews of aged-care packages. Have you any model of care that you think would work in that situation?

Dr Gonski : The GP should be the centre of care—they really should. Wherever anyone is, whether in an aged-care facility or at home, GPs should really be the first port of call. The local aged-care service should be the second port of call. It usually has geriatricians attached to it and, in many cases, very close links to ACAT, which are incredibly important and must not be fragmented at any time. ACAT are doing the entry point, really, to these aged-care facilities and the aged-care services. We have to work with them because we often do assessments and they often do assessments, and we need to be working as a team. So GP, geriatrician and ACAT all need to be integrated.

Dr Reyes : The other port of call for things like that would usually be the care managers or case managers for that specific healthcare provider. What I find in my experience is that we're losing a lot of service providers who used to offer that level of case management. For example, if the patient is on a level 2 home care package, they're finding that the patient's deteriorating—it happens to all of them at some stage—and then it needs to be upgraded, and, because there's no case management anymore, you lose that facility to just keep that patient within the same provider and manage the problems as they go.

Dr FREELANDER: And sometimes they're ending up at our local hospitals for that reason.

Dr Reyes : Yes, exactly. It takes one fall when nobody's looking to then have many injuries and even cause the patients to die sometimes.

Dr Gonski : But there should be no reason why someone who's just deteriorating because of their multiple medical problems or whatever it is should end up in an acute facility. I think this is what you're alluding to—there should be timely assessments in the right place so that people can plan what their next step is, and that's incredibly important.

Mr ZAPPIA: I have a couple of questions with respect to aged-care facilities. Dr Freelander made the comment that perhaps there are not too many geriatricians that visit people in aged-care facilities. Can you confirm if that's the case?

Dr Gonski : It's very much district specific. In my district, which is the Sutherland shire, we have a massive amount of input into every one of our facilities. Certainly, rural situations are completely different because they just don't attract the staff. But, even across metropolitan Sydney, there is an absolute variability.

Mr ZAPPIA: Is your service sought by the patient or the patient's family or by the aged-care facility?

Dr Gonski : We have made, over many years, relationships with GPs—very good relationships—and aged-care facilities and carers. We run outpatient clinics. We see people in their own homes, as assessments. We already make that relationship. So, they can contact us. We have a very good relationship with the GPs whereby we will not see people without a referral, because that will allow them to keep in the loop, and then we become very related to them as well.

When people are in aged-care facilities they should be contacting their GP first, if there's any deterioration, but we have now set up, as I said, some flying squads such that we firstly have indicated to the GP whether these residents are able to be seen immediately by us if they're acutely deteriorating, and we have about 95 per cent of GPs on board with that, so that the nursing staff can now see that someone's deteriorating. They would normally have put them in an ambulance but now can ring us and our team will go out and within two to four hours they will assess the resident, talk to the nursing staff, talk to the families, talk to the GPs and put up a management plan, and then they will treat them in their home, in the aged-care facility. And whether it's giving them intravenous antibiotics, giving them subcutaneous morphine because they're dying, or whatever, that will all be set up. That is not available in every district, but it's an increasing tool that we've got, which is really fantastic for everybody. Everyone's a winner, particularly the resident, who can stay in their own bed and not get confused in hospital et cetera.

Mr ZAPPIA: Having established a management plan for a patient, who follows up to ensure that the plan is being adhered to? Is that the centre staff, or is it the GP? Or is it both?

Dr Reyes : It should be both, because the—

Mr ZAPPIA: It should be, but, from your experience, are the plans followed through with?

Dr Reyes : Most plans, yes, because it is handed over to the care staff who do provide that direct care to the patient, who then should be able to let the GP know that, whatever the management plan was, it didn't happen.

Mr ZAPPIA: I guess I'm trying to get your experience back to the committee in terms of how well those plans are actually followed through with. I've got no doubt that there is a formal process that is meant to be followed through with—but is it?

Dr Gonski : I think one cannot generalise—

Dr Reyes : It would be very variable, and that would go back to the question around staffing ratios, because not all management plans are the same. Some will actually be very difficult. It's good in theory, but very hard in practice. So, it's also tough being at that forefront where I actually have to explain to the care staff, 'This is what you do with that wound; you have to dress it every day.' And when the patient's kicking and screaming when they're doing the dressings, it's not as easy as it is on paper. That's one.

Going back to our comment on the other question, the variability may be explained by the funding models. We're lucky. Both Professor Gonski and I work in institutions where we've managed to get funding for these initiatives through separate models to what the public hospital will provide. We find funding through ACI, through the Primary Health Network. But that's not available to all the local health districts, and that will be the explanation for the variability and one local health district having this very comprehensive package and not the other local health districts.

Dr Gonski : But you cannot underestimate the importance of setting up relationships, and those relationships need to be GP, staff in aged-care facilities and the people who are doing the assessment, such as geriatricians, psychogeriatricians et cetera. If you don't have those relationships then you may as well not put in a management plan.

CHAIR: I have a couple of questions. The first one's a very general one. I'm just wondering whether you could outline what the boundaries of the work that you do as geriatricians are, vis-a-vis other parts of the profession. When is the geriatrician called in rather than the GP or rather than the cardio or the gastro or some other specialist in the field?

Dr Gonski : There are a couple of easy answers to that. Firstly, specific conditions; we manage dementia. Psychogeriatricians often manage dementia, but the benefit of us managing dementia is that we usually have full services behind us. We work with integrated services and we can set up those services, which are so important in keeping people in their own home. So, dementia is a very major aspect for us. Acute deterioration and confusion—delirium—is very much ours, and that requires a medical person to find out why that person has markedly deteriorated quickly.

As people deteriorate, particularly as they're older, and their mobility deteriorates, their function deteriorates and usually, even if the person's got a heart problem, the cardiologist will be on what they can do, because the person's main problem now is functional deterioration rather than cardiac deterioration. It is the same with people who have Parkinson's disease. They've always been under neurologists, but there's an amount that the neurologist can do with medication et cetera, and they usually hand them over to us, either when their function deteriorates or when their cognition deteriorates. Cognition and function are really the things that sort of force people into our services.

The third one is the very old people who've got multiple medical problems, who are on multiple medications, and we need a specialist to oversee that, because some of these medications are actually causing some of their problems, and removing them makes them better. So, with a proper assessment we can make people much better. We can stop them falling, we can make them less confused and a whole lot of other things, too. So, they're sort of the three categories that would land people into our referral service.

CHAIR: I also want to follow up on the questions about the use of restraints. I note that your guidance is that physical restraints are used only in very exceptional circumstances. Would you say it is the same threshold for chemical restraints?

Dr Reyes : No.

CHAIR: In what circumstances would you primarily see chemical restraints used in, as distinct from physical?

Dr Reyes : The most common indications would be when there is obvious harm to the patient that is a result of their very abnormal behaviours. Technically these chemical restraints are antipsychotics, as a class of medications, and having psychotic features would be the primary indication—a very, very common happening in patients with delirium and a background of dementia. If they're having really vivid hallucinations, if they're having very bad delusions that are actually making them so paranoid that they can't eat because they think they're being poisoned, or they're kicking and screaming, harming other patients—which happens to us in the acute hospital all the time, because we don't have a dementia- or delirium-specific unit—they would be the two main indications: serious harm that the patient presents to themselves, significant distress, and significant harm to others.

CHAIR: And within an aged-care facility, who would make the decision about the use of restraints? Is it generally the management and their approach? Is it the medical practitioner? Is it the nursing staff at the aged-care centre?

Dr Reyes : It should always be medical staff who do the prescription—

CHAIR: It should be, but is that the case? I mean, do you find, for example, that some aged-care centres are known for using restraints when others aren't?

Dr Reyes : The problem is when they actually have them prescribed on an as-needed basis, which means they're on the medication chart to be used as required. So, when the behaviours escalate, the nursing staff or the care staff then have permission to use the medications. And where the problem happens is when that prescription is left open-ended and never reviewed, so then the patient goes on an increasingly escalating dose of the medication with no oversight from the medical professional.

CHAIR: To go to the second part of my question, in terms of the cultural treatment, if I can put it that way: do you find that at some facilities you would find a greater preponderance of use of restraints of either kind as distinct from other facilities? Is it a cultural issue within different centres, or a management issue?

Dr Reyes : To an extent, yes, and you will find that facilities that actually have less staffing, that then cannot address the behaviour by using non-pharmacological means or environmental means, will be the ones that will use those PRN medications more, because they just don't have the time to deal with the behaviour.

Mr GEORGANAS: Would that be the case in hospitals across the board as well—not just aged-care facilities, but in hospitals?

Dr Reyes : Yes, even in hospitals. We have code-black committees who then have to address this when it happens in hospital.

CHAIR: Just to focus on the restraints—I'm just worried that we might get diverted away from this, and it is one of the major issues—I note your comment that the practice is being less and less used. How big an issue do you think it is today? Is it still a significant issue, is it one that is now being managed down so well that it doesn't need a renewed focus from government, for example? Or is it in some places still a serious issue in terms of the way it's treated, or offered?

Dr Reyes : I think we're getting there but not yet there. I'd say we're halfway. So, that still leaves a lot for us to work on with education. It requires frequent reinforcement, and that's one of the things in nursing homes, where the turnover of staff can be quite quick. You do the education session this year, and then the next year it's completely new staff who will need that education again. So I think the reinforcement needs to happen on a regular basis.

CHAIR: Moving on to mistreatment in aged-care centres, I assume that you're not a body that keeps statistical records of these things, because it's not your job, but I'm just wondering whether, even anecdotally, you can paint a picture of how much mistreatment members of your association find in the aged-care sector. Is it common or is it rare?

Dr Reyes : In my experience, I'd say it's rare, because there is regulation within the aged-care facility. It's a mandatory reporting requirement. At least in my area of practice, I would say it's rare.

Dr Gonski : I think that it depends what you're talking about. If you're talking about elder abuse in the form of physical abuse from an aged-care facility's staff to a resident, I think it's still out there. I think it's due to basically frustration, often, on the part of the staff. They're tired, and these people are very, very difficult to look after. So I think it still is there. I think it is much less. If you're actually talking about people just basically being given medication for the sake of it, then I think that's definitely reduced, but it's still happening a lot. Again, if you put people in the wrong environment, they're more likely to require pharmacological medication which doesn't help them properly, so you should be moving them.

I look after Garrawarra Centre, which is a New South Wales nursing home. We have had some issues of elder abuse over the years. It is specific people doing this. We have certainly tried to address these issues, and over the years, particularly in the last 12 months, where we have had sanctions because of various reasons, I think we've done an incredibly good job to overcome that situation.

CHAIR: It's been put to me that one of the areas where most shortcuts are found and most treatment is lacking within the aged-care sector is in relation to incontinence management. Would you agree with that?

Dr Gonski : I would probably say behaviour management, but continence is right up there. It's a really big issue, and it can be managed.

CHAIR: It's also been put to me that, for example, something like three-quarters of injuries resulting from falls have their roots in incontinence. Is that—

Dr Gonski : I think that's an overexaggeration. People may have incontinence at the same time, but I don't think it's the cause of it. Certainly incontinence is a cause of falls—you're in a bathroom; you're incontinent; you fall over, whatever—but 75 per cent is massive—

CHAIR: Actually I think, from memory, I've got that figure wrong. It was 75 per cent in a different context. But a high proportion of all—

Dr Gonski : It's a part of it, but just remember that these people are often incontinent. Their continence does need management. For some of them, we can get rid of their incontinence completely. For some of them, we just have to have ways of dealing with their incontinence.

CHAIR: The final question from me is about the flying squads that you talked about that you've established to visit aged-care centres. I wasn't quite clear as to who the sponsor of those is. Is it the New South Wales public hospitals? How are they funded? Is it something the association has done off its own bat?

Dr Gonski : In our district—and we're both in the same district, which is South Eastern Sydney—it started when, basically, there was money thrown out by the district: 'Do you want to open up a model of care?' And that's not just aged care but across every single specialty. We got money to start this model of care, and it was incredibly successful, to the extent that the hospital and the district continued to fund it because it was so successful. Our data is incredible: this is what's happening to aged care and this is what's happening to aged-care emergency department admissions. Two of our hospitals started it. It was incredibly successful and continued by the hospital. We've now been able to get funding from the primary health network because they see the benefit of it. When they can't provide GPs, particularly when the patient is deteriorating, the squad goes out and deals with the problems.

CHAIR: Your primary health network covering the shire?

Dr Gonski : It's not only the shire; it's the whole district now. It's shire; it's eastern suburbs—

CHAIR: I didn't think there was anything beyond the shire.

Dr Gonski : No, that's only for people who live in the shire.

CHAIR: But what I'm getting to is: is it now a New South Wales-wide program, or is it still in your district?

Dr Gonski : It's totally across our district. It's well known by New South Wales, across New South Wales and across Australia and even to the UK. Some of the districts have taken it up and others haven't.

Dr Reyes : They go by many names. Sometimes they won't use 'the flying squad' as the name for the team, but they'll call it 'the geriatric outreach'. There are similar models across the state but varying to a certain extent.

CHAIR: But, for example, a primary health network's involvement—which I assume is federal funding—is going to the primary health network in your district; it's not a national campaign by primary health networks? Without wanting to lead you on to this answer, would it be fair to say that you would see merit in, for example, the federal government funding the primary health networks across Australia to look at and implement these solutions, or do you believe that's already happening with various mechanisms?

Dr Gonski : The primary health network get a lot of money from the Commonwealth, and they decide what they do with it. It's just that in our primary health network they saw the value of it.

CHAIR: The Commonwealth does set priorities.

Dr Gonski : I think it's a major priority.

CHAIR: For example, the money for ice treatment goes to the primary health network, but it's a specific pot of money that goes to the PHN for that purpose. Theoretically, the Commonwealth could say, 'Here's $X million for primary health networks to do Y.'

Dr Gonski : I think that would be a very wise move. At the moment we're getting our money from the after-hours segment of the primary health network, so they get money for after hours and that after-hours money is coming to us because we're running these after hours. But, if the Commonwealth said, 'Everyone, every district, has to have this money, and we're going to give it to the PHN to distribute to that district,' that would be a phenomenal outcome and would help older people a lot.

CHAIR: We wouldn't want to do it if the states were already paying for it themselves. Are there any further questions?

Dr FREELANDER: I have one quick question. It's been put to us that, in residential aged care, staffing levels are proportionate to the number of difficulties with elder abuse et cetera. Do you recommend staff-patient ratios, or do you have any views on that?

Dr Reyes : More than the actual ratio, it's the quality of care. So, instead of dictating that it needs to be four to one or six to one, if you make sure that that one person to those six patients is very competent and knows what they're doing, that would be the better target.

Dr FREELANDER: Leading on from that, do you have any views on the importance of having registered nurses rather than aged-care providers and enrolled nurses?

Dr Gonski : We actually were part of that discussion right here, and we were very much in favour of 24-hour RN existence in every aged-care facility. The reason is this. These residents are incredibly complex. They're on a lot of medications. They often have a lot of pain which needs treatment, and they also deteriorate very, very rapidly. Without registered nurses, it's very difficult to manage that.

Dr FREELANDER: Thanks very much.

CHAIR: As there are no further questions, I thank you for your time today. There was one thing I was going to ask, sorry. You referred, obviously, to the statistical basis for the flying squads and the crash in hospital admissions as a result of those. Do you have that documented anywhere that you could provide to the committee?

Dr Gonski : Absolutely. In fact, it's just been published in our journal. The published version you can just multiply dramatically across every district that has them.

CHAIR: Would it be worthwhile the committee coming to see a flying squad in operation, or is that a bit hard to—

Dr Gonski : You would be welcome, absolutely welcome.

Dr Reyes : Yes. We liaise with the New South Wales Ambulance and the local public hospitals. We actually take them on our visits as well, so that's open to you.

CHAIR: We may well pursue that.

Dr Gonski : You're totally welcome.

CHAIR: Thank you. Thank you for your time today. We're very grateful for your evidence this morning. If you could provide that additional information, preferably by 20 March—and the committee secretariat will be in contact about maybe organising a visit as well. Thank you for your time. You'll be provided with a Hansard transcript. If there are any errors or corrections to that, could you get back in contact with the secretariat as soon as possible as well. Thank you.

Dr Gonski : Thanks a lot.