Essay

System failure

WHEN I TURNED sixty last year, I entered a year’s worth of birthday celebrations with friends to mark the milestone. I was the first cab off the rank in March, with other birthday celebrations punctuating the subsequent months. There were seven of us in total, born in 1959, the same year as Barbie. To have your life run parallel to a plastic icon is more than a little strange, and although I may not have reached the heights of some of her sixtieth anniversary incarnations, such as Astronaut Barbie, I have tried to do my bit in the battle for gender equality waged by so many.

At each birthday celebration we reflected on decades of love, friendship and achievements, the ups and the downs, both personal and societal. We have indeed seen and done a lot, and we know we’ve led privileged lives. Being happy and healthy, we concluded that sixty is the new forty after all – even if our bodies are suffering from some long-expected wear and tear.

Yet many of the things that keep me awake at night do relate to getting older: the general ageing of the population and the increasing demand for health and aged-care services; inequities in health outcomes; the profile of our nursing and midwifery workforce; concerns around safety, quality of care and dignity in aged care; and the need to revise our concepts about retirement. Perhaps I have a unique perspective on such issues: my day job as the secretary of the Queensland Nurses and Midwives’ Union (QNMU) provides many different insights, and I’ve also had the privilege of sitting on two superannuation boards since 2001.

 

THE NUMBER OF us living beyond sixty-five continues to increase: in 2017, 3.8 million Australians were aged sixty-five or above, accounting for 15 per cent of the population. By 2057, modelling suggests that 8.8 million Australians will fall in that category, representing more than a fifth of us all.

Instead of catastrophising the ageing of the population, we should celebrate the significant improvements in life expectancy for Australians – while acknowledging that these are not, unfortunately, improvements for all. During the last century, life expectancy in Australia has improved by more than thirty years. According to the Australian Institute of Health and Welfare, we have one of the highest life expectancies in the world.

The enhancements in healthcare in my lifetime alone have been breathtaking. Rising health costs have accompanied longevity, and tend to be concentrated in the last few years of life. But there is much we can do to improve the equity, access, quality and sustainability of our health and aged-care systems.

Unacceptable differences in health outcomes – especially for Aboriginal and Torres Strait Islander peoples, those living in rural and remote areas, and the poor – continue to require urgent and concerted policy attention. Some groups simply do not have the same opportunity to age well: planning for aged care for Australia’s First Nations population, for instance, begins at age fifty rather than sixty-five, reflecting earlier onset of ageing-related conditions.

There has been a slight narrowing of the life expectancy gap for First Nations people in recent years. Each year for more than a decade the federal government tracks progress made against a number of indicators, but as the 2020 Closing the Gap report states: ‘While on almost every measure, there has been progress, achieving equality in life expectancy and closing the gap in life expectancy within a generation is not on track to be met by 2031. Aboriginal and Torres Strait Islander people still have a lower life expectancy than non-Indigenous people.’ Clearly, we need a more concerted effort in these areas, and one that goes beyond narrow health indicators to interventions that support the broader social determinants of health, such as secure meaningful employment, education and self-determination.

Significant gaps also exist in health outcomes for those living in regional, remote and very remote areas – the so-called postcode-based health gap. Providing timely access to clinically appropriate services outside large population centres is a constant battle, felt most acutely in Australia’s most decentralised state – Queensland. It simply costs more to deliver health and other services in these areas. Funding arrangements and models of care need to change to reflect this reality.

Current funding drivers are focused too much on remunerating providers of services rather than achieving optimal health for individuals and communities. Design of care needs to shift to become genuinely centred on the person requiring health services, and nurses and midwives have a key role to play in this most fundamental power shift. This begins and ends with human relationships. Though new technologies can certainly assist in bridging the geographic health divide, as tools they can never replace the power of human connection and compassion.

The burden of disease also continues to be disproportionally carried by the poor. Investing in the social determinants of health – addressing the root causes of health inequality rather than treating the diseases that are symptomatic of more fundamental problems – needs to be the focus in order to build a fairer and more sustainable health system. Reframing health and aged-care services to be genuinely person-centred and responsive will be key to this.

Although we have seen great advances in health for many, there is room for improvement, not only in terms of addressing the social determinants of health for all, but also in terms of addressing the problem of spiralling out-of-pocket healthcare costs. But the fact is that our universal health system delivers high-quality health services at an acceptable cost by international standards – around 10 per cent of GDP. Medicare is a potent symbol of Australian social solidarity and enjoys strong support across the community, as well as bipartisan political support.

Far too often, instead of celebrating the success stories of our health system during the past century, the focus falls on the ‘unsustainable’ cost of delivering health and aged-care services. At the risk of quoting Oscar Wilde inappropriately, this skewed focus leaves us at risk of knowing ‘the price of everything and the value of nothing’. Good health is a fundamental pre­requisite for a long and happy life.

Of course there are costs associated with providing the quality health services we so value. However, both quality care and financial sustainability can be achieved if we reframe our thinking from an approach that focuses on cost to one that appreciates value, as well as building upon innovations already occurring in healthcare – such as supporting nurses and midwives to work fully in accordance with their educational preparation. Innovative roles such as nurse practitioners, nurse navigators and continuity of midwifery care models are making a real difference in remote, regional and urban communities. They demonstrate so clearly the impact of new models of care designed around population needs.

 

AFTER MANY YEARS of campaigning for improvements to our health and aged-care system, I firmly believe change will only occur at its edges unless we address a number of key policy drivers. Three critical areas require particular focus: a broken funding model; inadequate governance arrangements; and power imbalances.

Funding health has always been a challenge, and reform in this area – long overdue – should be a priority for the Council of Australian Governments. As it stands, Australia’s state and territory governments are grappling with a funding model that is no longer fit for purpose. The current – fundamentally broken – model privileges medically driven activity over outcomes, evidence and wellness. A complex casemix funding model classifies different types of patients, their illness and costs associated with care, reducing health-related activity into widgets of ‘Weighted Activity Units’. The focus is primarily on undertaking an activity (such as a particular surgical intervention) rather than assessing if the outcome has proven successful in achieving its desired goal. It is a fixation on the pieces of the puzzle and not the whole. And this reductionist approach, which rewards activity rather than outcomes, is reinforced because some individual practitioners are remunerated on a ‘fee-for-service’ basis.

Treasury departments appear fixated on what they perceive as a bottomless pit of healthcare need – a need that is intensifying with an ageing population. With Queensland government health expenditure currently approaching nearly one third of total government budget expenditure, Treasury officials’ focus is understandable: the same picture is replicated elsewhere in Australia and around the world. But Queensland should be rightly proud of its hard-won advances in implementing innovative nursing models that enhance system sustainability. The state punches well above its weight in terms of advanced-practice nurses and midwives, employing around 27 per cent of Australia’s nurse practitioners, leading the way nationally with the creation of nurse navigator positions and expanding the number of community-based continuity of midwifery care models.

We have made these advances in Queensland in large part because of the different approach we have taken to industrial relations in the public sector through adopting an interest-based problem-solving approach. In this approach, both sides focus on identifying and solving common problems rather than on areas of disputation, as is the case in the traditional adversarial approach. Such a framework acknowledges that disputes and differences will always exist and provides a framework for potential resolution. It has also resulted in significant innovations in nursing and midwifery that have delivered better outcomes at lower cost.

But this springboard for ongoing sustainability is not fully appreciated. What remains critical is to reframe thinking so that health expenditure can be viewed as an investment that’s vital to productivity growth and community wellbeing rather than purely an expense on a balance sheet. We need a fundamental review of economic drivers to focus on quarantining funding for, and investment in, innovative models that deliver better outcomes, improve care co-ordination and produce long-term savings.

Take the 400 nurse navigators working in Queensland. The QNMU lobbied for the creation of this new role prior to the 2015 Queensland election – a role yet to be replicated in other states. Nurse navigators co-ordinate care for people with chronic and complex health conditions to keep them well and to keep them out of hospital. Preliminary reports of the role’s benefits are extremely encouraging: the first twelve months of the program in the Torres and Cape Hospital and Health Service resulted in a 61 per cent decrease in visits to emergency departments (ED), a 77 per cent decrease in unplanned re-admissions to ED, a 58 per cent decrease in hospital-bed days per month and a 61 per cent decrease in total hospital-bed days. In two months alone in 2018, $86,000 was saved in patients’ travel costs. Yet some hospital and health services continue to resist ongoing funding for these invaluable positions, while activity-based funding privileges medical-based activity at their expense.

Second, we need a radical overhaul of health governance structures and significant enhancements to transparency and accountability mechanisms. Health system governance has been a political hot potato for many years, with restructuring seen as its panacea. I have lost count of the number of restructures that have occurred in my working life – moving back and forth between various iterations of centralised and devolved structures – and the number of consultants employed to recommend and undertake them. An industry has been formed to ‘fix healthcare’, with ‘rent-seekers’ now an entrenched problem to fix rather than the source of solutions.

Effective governance is also vitally important. In recent years there has been a push for more professional and autonomous hospital and health service boards to mirror those of publicly listed companies. Professional and appropriately qualified boards are essential, as are enhanced linkages between health services and local communities. But our public hospitals and health services are not corporations. The community will always hold the government of the day to account for delivering quality health services and for any significant system failures. We need to make it clear where accountabilities lie and install robust mechanisms to ensure consistency of approach, collaboration and transparency.

One important mechanism to enhance transparency and accountability is the public reporting of health outcomes and other critical factors such as staffing numbers, skill mix and patient satisfaction. Such reporting builds community confidence in our health and aged-care system and also supports evidence-based decision-making. The Palaszczuk government has undertaken important work advancing this agenda through legislation, most recently through the Health Transparency Bill 2019, which Queensland’s Health Minister Steven Miles has described as featuring a planned interactive website like ‘the TripAdvisor for health care in Queensland’, enabling Queenslanders to make more informed decisions around the health and aged-care services they access.

Finally, we need to talk about both culture and power in health: how we can change the system to better support positive relationships, a culture of mutual respect and commitment to challenge, and evidence-driven practice so that power can be more evenly distributed. Health is riddled with power imbalances, and unfortunately it is the ‘consumer’ who too often has the least amount of power. The system still struggles to be genuinely person-centred. But the inherent information asymmetry in health is increasingly being challenged by better informed patients; paternalism is more readily challenged today, and questioning more welcomed. Yet so much time is also wasted on turf wars rather than outcomes for patients: there is a constant tension between and within clinical groups – and also between clinicians and bureaucrats.

Successive system reviews of health investment have failed to deal with this fundamental truth. We must acknowledge existing power imbalances and develop a plan to address them. This will be hard and contested work: redistributing power always is.

 

THE STATE OF our aged-care system should concern us all, not only those 200,000 Australians who reside in the country’s aged-care institutions or those of us who have passed the magical number of sixty-five years old. While the QNMU has fought a long campaign to improve aged care, the Royal Commission into Aged Care Quality and Safety is the latest in a long line of enquiries to focus on this subject. There have been thirty-five public inquiries into aged care over the past forty years – almost one per year. The issues have been well ventilated, and countless recommendations have been made to improve the system: what’s missing is the political will to act.

In May 2018, the QNMU conducted a secret audit of aged-care facilities in the thirty federal electorates across Queensland. The results highlighted shocking variability in hours of nursing provided to residents, from a low of 1.69 hours per resident per day in Moncrieff to 3.11 hours per day in Groom. Previously commissioned research found an average requirement of 4.3 hours per resident per day, and all facilities audited fell well below this level.

Such a level of variability is to be expected, as there is no requirement for minimum staffing numbers or having staff with the right level of skill, such as exists in the childcare sector. There isn’t even a basic requirement for one registered nurse to be on duty at a facility. Nor is there a requirement to tie funding to care provided. Put simply, there is a shortage of qualified nursing in aged care and this undermines the fundamental right of older Australians to access safe healthcare.

Our campaign to establish legislated minimum staffing numbers and skill mix, and greater accountability and transparency in aged care, intensified following our audit. In the wake of shocking revelations of neglect and abuse in aged care, some of which were subsequently aired in September 2018 on Who Cares?, the ABC’s Four Corners investigation, the federal government bowed to pressure and announced the Royal Commission.

While the situation was serious enough to warrant such a wide-ranging inquiry, there was concern this would delay meaningful action by simply kicking the can down the road ahead of the 2019 federal election. This is exactly what happened, with the two major political parties deferring any significant policy action until after the Royal Commission’s final report, not now due until November of this year.

The stories recounted to the Royal Commission have been devastating. The three-volume interim report handed down on 31 October last year was a damning read, saddening but not surprising to anyone paying even scant attention to aged care. The commissioners described aged care as a ‘sad and shocking system that diminishes Australia as a nation’ and concluded that ‘the system is designed around transactions, not relationships or care’.

In light of these interim findings, we have some serious soul-searching to do as a community. Can care of our older Australians continue to be reduced to a market transaction? How can we better demonstrate our respect and care for the elderly? How do these findings speak to who we are? How can we so undervalue elderly and vulnerable Australians, by denying their safety, dignity and access to healthcare? What does this say about our priorities as a society? The system is failing residents, their families and workers. And it will continue to do so for the next generation and the next until real change occurs. Collectively the Australian community must prioritise this industry and hold politicians accountable for fixing the mess.

The aged-care sector receives around $18 billion dollars a year in taxpayer funding (two thirds of which is spent on residential aged care), as well as significant contributions from each resident. The transparency and accountability around this funding is beyond inadequate, as is regulation of the system. This results in significant variability where residents and their families are effectively confronted with a lottery when placing a loved one in care.

Quality healthcare is a basic human right. Many elderly people are being denied access to safe health services due to inadequate laws mandating minimum numbers of appropriately skilled staff. The cost of failing to act for individuals in aged care, their families and staff is significant – both economically and culturally.

The lack of safe staffing laws in federally regulated aged-care facilities means state governments are forced to pay for the frequent and costly hospital transfers and stays that result from poor care: research in Victoria in 2017 revealed a jump of 25 per cent in transfers from nursing homes to hospitals in the previous twelve months, alongside a drop in the number of trained nurses employed by aged-care facilities from just over a third of staff in 2003 to just under a quarter by 2016.

 

AS MORE PEOPLE are living longer in retirement, closer attention must be paid to the elements that contribute to their comfort in that phase of their life. These include superannuation and personal savings; safe, affordable housing; and social connection and purpose – among others.

I am passionate about assisting Australian workers to enjoy a more comfortable and dignified retirement via their superannuation. Like many people my age, I haven’t had superannuation available for the entirety of my working life. Universal super was fought for and won by the union movement and achieved under the Hawke government, starting with compulsory 3 per cent occupational superannuation in 1983 through the Prices and Incomes Accord. It has gradually increased since, and the minimum superannuation guarantee contribution now stands at 9.5 per cent, and is set to gradually increase to 12.5 per cent by 1 July 2025.

As at 30 June 2019, Australian superannuation assets totalled over $2.9 trillion, making Australia the fourth-largest holder of pension-fund assets in the world. Over sixteen million Australians – two thirds of the population – have a superannuation account. According to the latest Melbourne Mercer Global Pension Index, Australia’s superannuation system is rated third worldwide behind the Netherlands and Denmark in terms of adequacy, sustainability and integrity. Australia’s B-plus rating highlights that our super system is fundamentally sound, but there are areas for improvement, including rising levels of household indebtedness and the need to increase personal savings.

This is an Australian success story we often fail to celebrate. So too is the representative trustee system that underpins the successful operation of profit for member superannuation funds. Each fund has a board where employer and union representatives work collaboratively to maximise the retirement incomes of the members. I have witnessed firsthand the power of such collaborations since I joined the first of two superannuation boards nearly twenty years ago. Having a diversity of experience, perspective and expertise at board level contributes greatly to the success of such funds.

But the super system is far from perfect, and it is not fair for all. Women are especially disadvantaged. According to research conducted by Women in Super (WIS) in 2014, women live on average five years longer than men, yet they retire with 47 per cent less super. Worryingly, 40 per cent of single retired women live in poverty, and older single women are the fastest growing cohort of homeless people.

In 2017 WIS launched its ‘Make Super Fair’ campaign to address this unacceptable situation. The problems result from a number of factors, including the gender-based pay gap, women taking time out of the paid workforce for caring responsibilities, and the higher proportion of women in lower paid and part-time jobs.

A number of superannuation-specific policy changes are foundational to this campaign. But more is required outside of super to address the problem of the disproportionate number of women living in poverty and the increasing number facing homelessness in old age. This requires a broad and creative policy response involving multiple parties, including government at all levels, super funds and individuals.

 

THE WORK THAT nurses do every day contributes fundamentally to healthy ageing. I come from a family of nurses – my mum and her two sisters; my oldest sister too. I grew up hearing the funny, sad and quietly inspirational stories of the difference nurses make in people’s lives. When I began my nursing training in 1983, I experienced for myself the often-unseen power of human caring that is nursing, and I realised the work was both inherently rewarding and a privilege to perform. Every day nurses – and midwives – make the difficult and at times existentially threatening bearable with their skill, knowledge, compassion and humanity.

The vital role nursing plays globally in delivering universal health and aged care was highlighted in a 2016 UK All-Party Parliamentary Group on Global Health report titled Triple impact: How developing nursing will improve health, promote gender equality and support economic growth, a groundbreaking report that reframed the narrow way in which nursing has traditionally been viewed. It led to the World Health Organization declaring 2020 the International Year of the Nurse and the Midwife.

Any recalibration of our health and aged-care system that is required to support future sustainability requires genuine acknowledgement of the value of these practitioners. They make up the largest component of the health workforce and provide an essential surveillance role. With a constant presence, they keep the system both safe and human.

Now, like the broader community, those who work in these professions are also ageing. In 2017, the average age of the Australian registered nurse was around forty-four years, and the average age of the midwife was forty-eight years. Urgent investment in workforce planning is required if we are to avert future skills shortages.

 

THE SOCIAL COHESION faultlines that exist in Australia and elsewhere in the world are a barrier to solving so many of the challenges related to ageing. Increasingly we seem unable or unwilling to focus on the common interests that unite us rather than the points where we differ. We fall into entrenched ways of thinking, lacking the time or readiness to actively listen to and consider other points of view.

This is worrying, as it stifles the creativity required to solve problems. So many appear to have lost the capacity to listen to alternative views or to develop and argue considered, evidence-based perspectives. Instead, we hold firm to our positions. It is easier to do so, and during uncertain times, with record low wages growth, record high levels of household indebtedness and the proliferation of insecure work, it is understandable that fear and anger are at the forefront.

This results in growing inequality and unfairness, and it should be no surprise that many who are feeling angry and fearful are being exploited by populist politicians who fail to address the root cause of these powerful emotions. This contributes further to declining faith in the political class. To address both this spiralling decline and the fracturing of social cohesion, we need to listen carefully to why people are fearful and angry before we act.

This process will be neither easy nor quick – but it is vital work. As I age, I see the importance of finding the root cause of a problem and developing long-term sustainable solutions. Yet so much conspires against this approach. ‘Short-termism’ continues to dominate many facets of our lives, reinforced by the pace of living in the twenty-first century and a mindset that demands both 24-hour connection and immediate responses. It is hard to find the bandwidth to focus beyond the immediate problems of the here and now.

As any nurse knows, in life-or-death situations the priority is to triage and deal with the most critical issues. This means that too often the important but not urgent work is de-prioritised, and this occurs at the expense of long-term sustainability. We are too often busy reacting to act purposefully.

 

AGEING WELL REQUIRES a lot of different components, including being healthy, financially secure and socially well connected – all are important elements of community wellbeing. We also need the structures, processes and resources in place to support us as we age. These are issues I focus on daily in my work on behalf of members and the broader community. Building a fairer and more inclusive Australia in which to age requires particular effort and we must focus on what really matters to people. I have seen firsthand how powerful it is to advance shared interests and the innovation that can result.

As I enter my own seventh decade, I reflect on how fundamentally the world has changed during my lifetime. More and more I appreciate the importance of having a framework of clear values to act as a touchstone for decision-making, and I know I am fortunate to have my nursing, midwifery and union values to anchor me. Having dealt with a lot of significant change in my work, I now actively resist the urge to immediately respond to any claim or any call. Instead, I try to stop, breathe, listen and reflect.

No one person has all the knowledge or the solutions. There is so much to learn from others, and we make better decisions if we genuinely consider and respond to alternative points of view. And as I write this, I realise how much I sound like my grandmother, Grace!

What concerned Grace, a devout Methodist from Eumundi on Queensland’s Sunshine Coast, is so different in so many ways from what worries me today, but the fundamentals remain the same. I’ve departed from her views on alcohol and dancing, but many of her other beliefs remain with me, especially around collectivism and commitment to the common good. The challenge is to remain anchored by what is fair, being consistent and accountable for your actions (and inaction) and treating people the way you want to be treated.

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