Smaller and local should be heart of aged care

The pandemic has forced us to confront, in unblinking horror, the plight of the frail aged in institutional care.

St Basil's Aged Care at Fawkner, Melbourne. Picture: Andrew Henshaw

If there is one good thing that has emerged from the pandemic, it is that it has forced us to confront, in unblinking horror, the plight of the frail aged in institutional care.

We have become almost blase about the almost routine complaints of abuse and neglect in residential aged care, comforting ourselves with inquiries and royal commissions. But the pandemic has shown us what can happen in relatively good institutions, not because of aberrant behaviour by staff but in the normal everyday operation of an institution.

In an epidemic the infectious cycle is partly propelled by the nature of the institutional structure itself and, consequently, the infection rate and the subsequent mortality rate of very old residents is always going to be high.

Understandably, the families of the frail aged residents don’t see it that way. Their expectations are different. They expect Mum to keep on living until a quiet dignified death. This was indeed what my father had, although my mother was less fortunate. She died in hospital, prevented from returning to her suite because of a gastric infection that had taken hold. So, the care of the aged and the fate of the aged in this is a problem seen on two levels.

There are two different sets of values at play here: the personal and the structural. The disconnect between the two is palpable. One only has to see the grief and trauma of the families of relatives who have died of the virus to feel that disconnect. I felt very sorry for the families at St Basil’s in Melbourne.

I know most families, particularly traditional families, put their parents into institutional care only as a last resort, when they have run out of care-at-home options. Most of us know the term “professional care” is an oxymoron. True care comes from the people who love you, not from people who are paid to do it, and care at home, with family involvement, is always the better option.

There are home-care pack­ages, but sadly the needs of the aged often outlive the amount of paid help the package can provide, particularly in cases of dementia. Consequently, residential care is a type of palliative care. However, the cost at this stage, despite government subsidies, is sometimes almost prohibitive and usually requires the sale of the family home.

The sheer demographics of a rapidly ageing future, caused by a decline in the birthrate, are daunting for the current system of aged care. But on the personal side, the prospect of any family involvement is shrinking.

The important demographic numbers are what economists call the dependency ratio: the ratio of working-age people to people of traditional non-working age, over 65. In 1978, the dependency ratio was 7:0, today it is 4:2 and by 2058 it will decrease to 3:1. Liberal senator Concetta Fierravanti-Wells, a former opposition spokeswoman for ageing, pointed out in her comprehensive submission to the aged-care royal commission that this would have serious consequences for the funding of aged care under the present model.

An even scarier statistic is the dependency ratio of those of working age to those over 85. In 1978, that ratio was 101.4 workers to every one person over 85. Now that ratio is 32.5:1 and it will decline to 13.6:1. And because of better health there will be even more people over 85. So this has a direct impact on the prospect of our ability to continue to pay for aged care and personal family involvement.

Fierravanti-Wells has some radical suggestions about structural change and, unlike a lot of politicians and theoreticians, she had her own experience with her Italian-born father. She is particularly aware of the problems of people who cannot speak English or who revert to their birth language. She is also aware of the three Gs of aged care: guilt, grief and greed. Her solutions are complex and will require a complete restructuring of the system. However, at its heart she recommends several key changes within a five-year agreement.

She recommends that aged care be integrated with the health system under one Medicare umbrella. This would provide certainty of funding and better med­ical care. She also recommends that packages and bed licences should be abolished and aged care should be provided in smaller “hubs” that would allow a full suite of locally provided services.

In my view, smaller and local is the crux of reform. The aged care system is at present an inflexible, bureaucratic nightmare, and the complete reliance on residential care often causes great distress, and cuts people off from their mental and emotional roots. This would be ameliorated if aged care was handled at a more local level. It also would allow for better and more easily available home care, which is cheaper in the long run.

Doubtless some people would like to remove their parents from an aged-care facility because they don’t have the virus but are told they can’t or have no home options because they have sunk every penny into residential care.

The pandemic has shown us that aged care is not just about who funds what — it is a pressing cultural and social issue. It is about the lack of value of old people, and the sheer unwillingness of some families to look after their own, even within residential care. According to the Australian Institute of Health and Welfare, in 2018 the most prevalent diagnosis in aged care was depression — 49 per cent.

The more successful placements in residential aged care are people from families who regard the “carers” as helpers or partners in the care. This frees up family members to do other more stimulating things such as visits to cafes or galleries — even though in my case this was often difficult and sometimes hilariously chaotic, but the thrill on my mother’s face when we returned from one of these expeditions was worth it.