Last week, the Royal Commission into Aged Care Quality and Safety (Royal Commission) held its Canberra hearing from 9-13 December 2019. It inquired into the interfaces between the aged care system and the health care system, including both Commonwealth and state/territory programs. It also examined whether older people, particularly those living in residential aged care facilities, are able to access the health services they need as they age. Here, we summarise the activities of each day.
Day 1 – Monday 9 December
Senior Counsel Assisting, Peter Gray QC, opened the Canberra hearing with an outline of the key themes for the week, all relating to the interface between aged care and general health care services. He noted that the Royal Commission will explore systemic deficiencies at a national level with a view towards improvement through wide reaching reform. The first witness to give evidence was Rhonda McIntosh, who spoke of the difficulty her father experienced in gaining access to proper medical care at a Melbourne aged care facility. Her family were given no choice as to who would treat her father and the facility failed to address his cardiac problems. Kristine Stevens then spoke of her parents' experience accessing health services during their time in aged care, detailing their rapid decline upon entering respite care and the absence of a GP to approve medication administered at the facility. A panel of witnesses then gave evidence together, with Dr Troye Wallet, GP; Dr Paresh Dawda, GP; and Susan Irvine, RN, discussing their proposal for an appropriate funding model to provide the improvements required to ensure residential aged care facilities and GPs are working to adequately attend to the needs of residents. The panel explored the proposition of blended payment arrangements, the utility of a memorandum of understanding and shift towards an integrated practice unit. Dr Anthony Bartone, President of the Australian Medical Association; and Associate Professor Mark Morgan of the Royal Australian College of General Practitioners were the last witnesses for the day. They spoke to the way in which GPs are increasingly having to respond to patients suffering from multiple co-morbidities that require a greater degree of skill and knowledge, a problem that is compounded by inadequate funding and remuneration schemes.
Day 2 – Tuesday 10 December
Jennifer Walton was the first witness for the day. She outlined her mother's experience as a dementia patient in a residential care facility that relied heavily on external transfers to address a range of medical issues which ought to have been handled within the facility. The second and third witnesses, Dr Ellen Burkett and Dr Carolyn Hullick of the Australian College for Emergency Medicine both highlighted the importance of there being a will to undertake extensive change across the health care continuum in order to improve the quality of care provided in the aged care sector. Dr Terry Nash and Megan Beecroft of CARE-PACT, along with Dr Michael Montalto of Aged Care Imaging Pty Ltd, told the Royal Commission that the role of the GP is central and fundamental to a successful health care model and advised that any systemic implementation that does not address the constraints placed on GPs will not succeed. Paramedic, Tess Oxley, was the final witness for the day, highlighting the necessity for paramedics to receive adequate information from aged care facilities in order to avoid unnecessary situations and inefficiencies. She noted that the availability of information differs between institutions, not from person to person.
Day 3 – Wednesday 11 December
Counsel Assisting, Richard Knowles SC, opened the third day of the hearing by reading a statement from Hamish McLeod, in lieu of his appearance. The statement questioned the scope of the responsibilities required of approved provers in the context of hospital and health care transfers. He noted that this was illustrative of the need to improve the overall standard of care. Kate Davis then gave evidence of her mother's experience living in multiple aged care facilities and detailed the struggles that she faced communicating with the facilities regarding her mother's care. Thomas Woodage of Baptistcare; Judith Gardner of Buckingham Gardens Aged Care Service; and Fiona Lysaught of the Whiddon Group then spoke to their collective experiences in managing residential aged care facilities and the arrangements typically in place that surround GP visits. The panel agreed that the current arrangement between facilities and health providers is inadequate. Two palliative care nurses, Nikki Johnstone OAM of Calvary Public Hospital; and Peter Jenkin of Resthaven Incorporated gave evidence together on the imbalance between the quality of care provided to older Australians and that afforded to the broader community. The pair noted that there must be more emphasis on training staff to improve quality of care for residents at the end of their life, commenting that pain in end of life patients is under diagnosed, under recognised and under treated. The final witness for the day was Professor Christopher Poulos, Consultant Physician in Rehabilitation Medicine. He spoke to the deficiencies he perceived in the MBS model, particularly the complex geriatric assessments and management of treatment plans which are time consuming tasks not accounted for when determining remuneration under the MBS model.
Day 4 – Thursday 12 December
The evidence given on the fourth day of the hearing took the form of three separate panels. The first panel comprised Professor Leonard Gray of the University of Queensland and Professor Leon Flicker of the University of Western Australia. The pair agreed that interaction between care entities is crucial, and advocated for a national framework to provide a clear understanding of scope and responsibility of different bodies. Both called for increased information sharing and a radical overhaul of the existing system. The second panel was made up of government agency representatives, including Dr Nigel Lyons of NSW Ministry of Health; Dr John Wakefield PSM of Queensland Health; Dr Christopher McGowan of SA Health; and Dr Andrew Robertson CSC PSM of the WA Department of Health. The panel expressed their views on the need for further clarification on roles and responsibilities, as well as designating coordinators in order to effectively ensure adequate access to health care for aged care patients. Some panellists warned of merely suggesting new proposals, and called for actual identification and definition of the government's vision for aged care. The final panel was made up of Federal Government representatives Glenys Beauchamp PSM of the Commonwealth Department of Health; Professor Brendan Murphy, the Chief Medical Officer for the Australian Government; and Penny Shakespeare, also of the Commonwealth Department of Health. The panel raised concerns with several statistics that had been presented as evidence to the Royal Commission, noting that many residents accessed care through Veterans' Affairs and other schemes, which skew the statistics other witnesses may have provided. Glenys Beauchamp did acknowledge that, based on the evidence presented to the Royal Commission, there was an obvious failure within the health system regarding the coordination of care.
Day 5 – Friday 13 December
The final day of the Canberra hearing opened with direct evidence from Rhona Payget, who spoke of her dissatisfaction with her mother's treatment at a residential facility as well as the difficulty she encountered in getting information from the facility. Dr Claire Skinner then spoke of her experience working as a Specialist Emergency Physician at Hornsby Ku-ring-gai Hospital, detailing the large amount of transfers the hospital received from aged care facilities. She stated that approximately 65% of transfers were unnecessary. She further noted that it would be kinder on aged care patients to treat them somewhere other than a hospital, where the chances of infection or a fall are reduced. Terry Symonds of the Department of Health and Human Services, Victoria; Ross Smith of the Department of Health, Tasmania; Michael De'Ath of the ACT Health Directorate; and Dr Maggie Jamieson from the Northern Territory Department of Health were the final witnesses of the Canberra hearing, speaking together on the responsibilities of aged care facilities. The panel agreed that aged care facilities should bear the responsibility for connecting residents with health care, and that the provision of basic equipment and facilities as well as arranging transport for residents, would fall within this responsibility. Peter Gray QC observed in his conclusion of the Canberra hearing that aged care service providers are funded to provide nursing services but not medical services. He noted that they assist medical practitioners with their service delivery under the quality of care principles. However, he reiterated the need for the Department of Health to better clarify the role of aged care service providers, and ensure there are no gaps in the delivery of aged care services.