July 6, 2022

Aged care

Age is just a number

By Russell Marks
Photo of the hands of an elderly woman. Image © Yui Mok/PA Wire

Image © Yui Mok/PA Wire

The slow decline of Australia’s aged-care system into a bureaucratic nightmare

Last year, my grandmother got old. That’s how she sees it, anyway. Until May 2021 she’d been getting out and about – lunches, social clubs, day trips on coaches. Then she noticed one of her socks was soaked wet. Diabetes had converted a bruise on the back of her leg to a seeping, infected wound. Her GP cleaned it out, bandaged it and ordered her to sit while it healed. Nurses began arriving twice weekly at her home, where she lived alone, to dress it. Before long, they also found pressure sores on her bum. Her leg wound eventually healed, but her pressure sores never have. She lost strength, stability and confidence.

To the world, my grandmother had been getting old for some time. She lived through the London Blitz and then worked on Fleet Street for a news agency, before migrating to Australia to marry a man she’d met while he was recuperating after five years as a prisoner of war. But she’s 96 now. The federal Department of Veteran Affairs (DVA) has been supplying a cleaner to her house for a decade. She’s had Meals on Wheels for about that long too. Her hearing and manual dexterity have been on the slide for a while. Someone with greater foresight, or with a more proactive GP perhaps, might have gotten assessments for extra services before they became urgent. But my grandmother has never been a master of consequential reasoning, or what is sometimes called “if-then” thinking. She’s big on routines, increasingly so as she’s aged.

I returned to Adelaide after 15 years away at around the time the leg wound began leaking pus. Anticipating decline, I called DVA and was told that she was close to maxing out her veterans’ services. If she needed more she’d have to get a Home Care Package, provided by the My Aged Care service, which is administered by the health department. Thus I chased my first white rabbit into the bureaucratic wonderland that is Australia’s aged-care system. Both Veterans and Health are federal departments, answerable to the same cabinet and funded out of the same budget. The Home Care Package offers more of the same kinds of services she was already receiving under DVA. It followed that, to access a Home Care Package, she’d need an entirely new assessment.

So, I called My Aged Care. We were lucky, I was told, because a spot had just opened up and an assessor could be at my grandmother’s house in five weeks. But, I asked naively, what if she needed services before then? A newbie question, I realise now. She wouldn’t even be getting services after then. The process is flowcharted on the reams of documentation we began to receive: following the assessment would come the waiting period, which would last up to a year. But what if she deteriorated during that time? Home Care Packages come at four levels, depending on assessed need. Would services be offered at my grandmother’s level of need on the date her package becomes available? No, the call centre operator confirmed, services would only be offered at her level of need assessed on the date of her assessment, which by then might have been 12 months earlier. In a moment of pique, I challenged the operator to explain the bureaucratic logic at play, before immediately apologising.

Meanwhile, I could arrange some more assistance for my grandmother – a physiotherapist, an occupational therapist, a dietician – under DVA. We just needed her GP to make some referrals. Good GPs are remarkably effective at opening doors and advocating for their patients. My grandmother’s GP is good at prescribing painkillers and antibiotics. She’d been a patient of his for longer than I’d been alive, and their relationship had achieved a state of nirvanic enmeshment. He was making unannounced house calls, going back and forth to the chemist himself, and even prescribing potato chips for low sodium levels in her blood. I just couldn’t conjure a referral out of him. He’d miss scheduled appointments altogether, and he wouldn’t answer my calls or respond to my text messages. So I took to visiting her at odd times in the hope that I’d catch him. My grandmother wouldn’t hear of seeing a different doctor, and before long we couldn’t get her into a car to take her to one – even if we could have found one that hadn’t closed their books to new elderly patients.

Had she applied for a Home Care Package a decade ago, my grandmother would have likely waited about a month and a half following her assessment. Average waiting times have blown out ever since, according to Productivity Commission data. They’d reached three months by 2015–16 in South Australia, more than six months in 2018–19, and were sitting at eight months at the point her leg started leaking last year. Average waiting times are longer in South Australia than everywhere else in the country except the ACT, where people are now waiting nearly a year.

What I didn’t appreciate was that the wait is not over when the package is eventually offered. At the end of February 2017, the Turnbull government overhauled Home Care Packages. Until then, each package had simply been assigned to the “provider” – generally a church-based NGO such as Anglicare or CatholicCare – which had won the tender for each geographic area. Now, consumers had the privilege of choosing (which means finding) their own provider. The biggest winners in the new, post-2017 aged-care market have been private, for-profit providers, whose share of the Home Care Package market has tripled in SA and grown nearly five-fold in Victoria, where they now account for nearly a third of all providers and are by far the largest provider type. Aged care is a lucrative business for service providers (unless of course you’re a worker who actually provides services).

By the time she was offered a Home Care Package earlier this year, my grandmother had lost the ability to hear people speaking bureaucratese on the phone. So I did the ring around. I must have spoken to 30 call centre staff at 20 corporatised providers. I kept getting the same response: “Unfortunately, we’ve closed our books to new customers for the time being. You’re welcome to call back in six weeks, by which time we may have reassessed the situation.” At the very moment that COVID-19 had ceased to be national news, it was taking its toll in Adelaide. Already enduring chronically poor pay and conditions, Adelaide’s aged-care workforce began dropping like flies after borders opened to the eastern states last November. The National Skills Commissioner, Adam Boyton, delivered the final report of an in-depth study of the aged-care workforce, requested by Scott Morrison in March 2021, in September that year. It still hasn’t been released publicly.

My Aged Care gave us just under two months to find a provider. After six weeks of failing to find one, I called the 1800 number on the letters “posted” to my grandmother’s MyGov inbox – the one she wasn’t aware she even had, having dropped out of the technology race somewhere between LP turntables and VCRs – to arrange an extension. We could have another month, but no more. If we didn’t sign a service agreement with a provider in that time, she’d go back onto the waiting list. “But what if staffing shortages mean there’s no provider with any capacity to offer us a package?” I asked. The call centre operator corrected me. She’d already been offered a package, by the government. I floundered for the bureaucratically correct words. But it didn’t matter what words I used. My grandmother would be punished for market failure because of some very un-markety rules imposed by the market’s bureaucratic designers.

Meanwhile, she’d begun to fall over. The more she sat, the less her pressure sores healed, and the less her sores healed, the more she sat. And all the while, the weaker and wobblier she became. It’s a common pattern of decline among the elderly, and for that reason I wanted a physio and an OT to be involved, keeping her active and mobile. Her strength vanished. The last two falls landed her in hospital, the second admission resulting in a stern recommendation to not go home alone. The hospital’s placement team found her respite “with a view to permanency” at a nursing home. “We don’t use that term anymore,” an intake manager with a Julie Bishop hairdo and a designer suit gently chided me. “We’re residential aged-care facilities now.”

The Royal Commission into Aged Care Quality and Safety identified the extraordinary waiting lists for Home Care Packages as the reason so many older Australians are being forced into residential care against their will. Australia now spends less than half, proportionally, of what comparable countries spend on aged care. In all jurisdictions there are many fewer operational aged-care places per 1000 people aged 70 or older than there were a decade ago. The commission’s more ambitious recommendations for systemic reform will cost at least an extra $150 billion over the next decade. Yet Australia’s major parties colluded last year to retain the Morrison government’s Stage Three tax cuts, which will gouge $184 billion out of the federal budget during that same period.

Sometimes, though, I wonder if resourcing is even the main issue. Australia’s aged-care system is representative of what has happened – what we’ve done – to the nation’s public services generally. Across housing, health, disability, social security, child welfare and justice, outsourced agencies have become impersonal and rigidly bureaucratic. Access has become increasingly improbable even as public budgets have expanded. The language of choice and agency has hidden what is really a Great Australian Straitjacketing. There are winners here, but not among workers or “customers”.

A few years ago, my grandmother tried to get hearing aids. She spent thousands of dollars and made treks all over Adelaide, but couldn’t find a device that she could use, with her narrow ear canals and numb fingers. At the aged-care facility, the intake manager mentioned an audiologist. I signed up with unabashed enthusiasm. A couple of weeks later I took a phone call, not from the audiologist but their “customer liaison manager”. “We’ve fast-tracked her replacement devices,” I was told. “You’ll just need to complete the stat dec and send it through.” Stat dec? “Yes, you just need to declare that she’s lost her devices, and the department will replace them at no cost.” But she hadn’t lost her devices. They simply hadn’t worked for her. I explained that what she needed was help to fit them each morning and turn them on, some rehabilitation to help her learn how to hear again through them, and perhaps a commitment to try other devices if the first ones were unsuitable. “We don’t really offer that,” I was told. “We’re simply her audiology services provider.” The customer liaison manager explained that the provider got a package of money from the department to provide audiology services to my grandmother for a five-year period, which really only equates to annual assessments and ordering replacement devices. “So just to confirm,” I recapped, “as her audiology services provider you can’t actually provide her with any audiology services?” “Well, we wouldn’t put it quite like that, but no, we don’t offer rehabilitation and ongoing assistance.” Sounds about right.

Russell Marks

Russell Marks is a lawyer and an adjunct research fellow at La Trobe University. He is the author of Crime and Punishment: Offenders and Victims in a Broken Justice System (Black Inc., 2015). 

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