Quotes of the Week

“There are some people who seem to find it a very funny circumstance that last week, in full daylight, and in a main street of Cooktown, two black troopers, with their clothes in the same condition as those of a clumsy butcher’s apprentice, fresh from the shambles, exhibited a naked black girl, not twelve years old, as their newly caught prize. This young slave, taken by force . . . has since been transferred, either for payment or as a gift, to a citizen in this town, whose property she has now become. What were the circumstances that attended, or immediately followed, her capture we do not know, nor do we very much care to inquire ...”  [ Journalist & author Carl Feilberg writing in the Cooktown Courier in January 1877 ]


“Adding a new level of fear and uncertainty onto that with the findings coming out of a royal commission is going to harm the community as well as the industry,”  [CEO Clarence Village Ltd Duncan McKimm acting as an apologist for the aged care industry in The Daily Examiner ahead of the Royal Commission into Aged Care Quality and Safety]

Aged Care in Australia 2018: why government and the aged care industry make one want to weep in frustration

"The true measure of any society can be found in how it treats its most vulnerable members." [Attributed to Mahatma Ghandhi]

A little over five months ago the ABC program "4 Corners" asked people to contact its office to talk about their experience of the aged care system as staff, client or family member of an older person. 

Over four thousand Australians responded and the "Who Cares?" episode was produced and then aired on national television on 17 September 2018.

The day before this episode was scheduled for viewing Prime Minister and Liberal MP for Cook Scott Morrison made a rush announcement of a Royal Commission into Aged Care Quality and Safety - no terms of reference and no start date specified.

This royal commission if it goes forward this year will be the 21st review of the aged care system since 1997 - that's 21 reviews in 21 years.

Twenty-one years in which not one federal or state government has come to grips with the fact that there is a two-tier care system in operation based on the older person's ability to pay.

This plays out almost as apartheid in many aged care facilities, with separate wings in the building/s, separate nursing & other staff, separate meal choices and recreational activities.

It is also twenty-one more years in which older people of limited means have been almost warehoused. Receiving at best what can only be described as benign neglect and at worst extreme abuse.

No-one appears to being asking why so many older people entering residential care die within four years of admission (with death occurring on average around 2.5 years after admission) and why there is such a high percentage of premature deaths.

The incidence of premature and therefore potentially preventable death from the 11 principal external causes identified in a 2016 epidemiological analysis is apparently not going down over time and over the last ten or so years appears to be rising.

For over two decades registered charities, consumer groups and government watchdogs have never truly comes to grips with the basic realities of this two-tier care system.

A system which sees vulnerable older people verbally abused, threatened, physically beaten and deliberately denied appropriate basic care - reports of which can be found in the records of the federal Health Care Complaints Commission, state agencies such as the Nurses and Midwifery Council of New South Wales and in the media.

The day after the "4 Corners" program went to air, one representative of a registered charity which purports to represent older Australians was on national television condemning the types of abuse revealed in this program.

However, in the next breath - and almost in denial of such widespread abuse - he was talking about the need to understand why there was also excellent care in the aged care system and how residential aged care providers which meet or exceed Commonwealth aged care standards need to be rewarded.

He talked about some aged care providers being "world class" until the interviewer brought him back to looking at the ugly truth of the situation.

He was not alone in demonstrating how difficult it is for those associated with aged care to steadily fix their gaze on this seriously flawed system and insist that it be genuinely reformed.

It is hard not to see Scott Morrison's announcement of a royal commission as one meant to pre-empt the "4 Corners" program ahead of the Wentworth by-election on 20 October 2018 - given that the Minister for Senior Australians and Aged Care & Liberal MP for Hasluck Ken Wyatt appeared lukewarm about the need for a royal commission into the aged care system just last month and, in the face of contrary evidence the Prime Minister continues to deny the controversial federal funding cuts to the sector by way a tweak of the Aged Care Funding Instrument to the tune of $1.2 billion in efficiency savings in the 2018-19 Budget.

Waiting for home care in Australia in 2018

There are now 108,000 older Australians on the waiting list for Home Care Packages.

On this list are individuals who have:

* not yet been approved for home care;

* been previously assessed and approved, but who have not yet been assigned a home care package; or

 * are receiving care at an interim level awaiting assignment of a home care package at their approved level.

Waiting time is calculated from the date of a home care package approval and this is not a an ideal situation, given package approval times range from est. 27 to 98 days and the time taken to approve high level home care packages is now than twelve months - with actual delivery dates occurring at least 12 months later on average.

Labor’s Shadow Minister for Ageing and Mental Health issued a statement which pointed out that “With the waiting list growing by almost 4,000 older Australians in just three months, the 3,500 new home care packages a year committed in the Budget won’t come close to keeping pace with demand”.

With more than half the applications for permanent entry into residential aged care taking more than 3 and up to 8 months to be met, this is not going to be a go-to first option in any solution for this lengthy home care waiting list - even if enough older people could be persuaded to give up the last of their independnce and autonomy.

By June 2017 New South Wales had the largest number of persons on the home care waiting lis at 30,685.

Given the high number of residents over 60 years of age in regional areas like the the Northern Rivers, this waiting list gives pause for thought.

Then there is this side effect of the waiting list and home care start dates identified by Leading Age Care Services Australia (LAGSA):

Consumers with unmet needs and unspent funds

LASA has undertaken an extensive review of the disparity that exists in the current release of HCP assignments, noting that there are substantial numbers of consumers on HCPs with either unmet needs or unspent funds . This bimodal distribution of home care package assignments reflects a mismatch between consumer package assignment and a consumer’s current care needs. The mismatch appears to be a function of the extended lapse of time that exists between approval assessments and package assignments. Until this dynamic is sufficiently addressed by Government, LASA expects that providers will be faced with a unique set challenges in 2018 when providing care to HCP consumers. This is likely to increase the need for regular care plan reviews in the context of unmet needs and unspent funds. This dynamic could be considered more closely within the context of developing a single assessment workforce.

Thus far Australian Minister for Aged Care and Liberal MP for Hasluck  Ken Wyatt is offering no insight into federal government thinking on this issue.

Sources:

https://gen-agedcaredata.gov.au/Topics/Admissions-into-aged-care

https://www.aihw.gov.au/reports-statistics/health-welfare-services/aged-care/overview

https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/09_2017/assessor_fact_sheet_-_home_care_package_wait_times_v1.0_0.pdf

https://gen-agedcaredata.gov.au/Resources/Home-care-packages-program-data-report-2017

https://lasa.asn.au/wp-content/uploads/2018/02/270218-Consumer-directed-care-in-home-care-packages.pdf

Elder abuse and profit shifting go hand-in-hand in the age care sector?

Any regular reader of online news would have seen mentions of elder abuse, neglect and sub-standard health care over the years.

hellocaremail.com.au, 2017:

Elder abuse is a critical issue in aged care homes, with thousands of cases reported to the Health Department every year…. In 2016-2017, there were 2853 reports of “reportable assaults’’ and 2463 allegations of “unreasonable use of force”.

Australian Law Reform Commission, Elder Abuse (DP 83), Abuse and neglect in aged care, 12 December 2016:

1.34   Stakeholders reported many instances of abuse of people receiving aged care. These included reports of abuse by paid care workers[55] and other residents of care homes[56] as well as by family members and/or appointed decision makers of care recipients.[57] For example, Alzheimer’s Australia provided the following examples of physical and emotional abuse:

When working as a PCA [personal care assistant] in 2 high care units, I witnessed multiple, daily examples of residents who were unable to communicate being abused including: PCA telling resident to ‘die you f---ing old bitch!’ because she resisted being bed bathed. Hoist lifting was always done by one PCA on their own not 2 as per guidelines and time pressures meant PCAs often using considerable physical force to get resistive people into hoists; resident not secured in hoist dropped through and broke arm—died soon after; residents being slapped, forcibly restrained and force-fed or not fed at all; resident with no relatives never moved out of bed, frequently left alone for hours without attention; residents belongings being stolen and food brought in by relatives eaten by PCAs.[58]

1.35   The ALRC also received reports of other forms of abuse, including sexual[59] and financial abuse.[60] Restrictions on movement[61] and visitation[62] were also reported. Many submissions also identified neglect of care recipients.[63]

The Sydney Morning Herald, 15 October 2017:

Across NSW, 58 per cent of aged care workers surveyed said they have not been able to provide the level of care residents deserved because of budget cuts. Of those, 80 per cent said staff shortages were the main barrier to providing proper care.

The Courier-Mail, 19 April 2018: 

PROFIT-HUNGRY aged care companies are charging fat “administration fees” to skim up to 40 per cent of government payments for in-home nursing care.

More than 100,000 elderly Australians are on a waiting list to receive as much as $50,000 a year in a “homecare package” to pay for nursing, housekeeping or companionship at home. But an investigation by The Courier-Mail has revealed that some home-care companies are pocketing as much as $19,000 of the taxpayer cash through hefty “administration” or “case management” fees.

The fees are billed on top of hourly charges for home help – leaving clients with less cash to spend on in-home care such as nursing. And if clients want to switch to a cheaper provider, they are being slugged up to $1000 in “exit fees”.

The Age, 3 May 2018:

Scandals, including a recent national audit showing 600 aged-care homes failed in the past five years to provide minimum standards, prompted a government review. The Coalition, accepting a key recommendation, has ended the ridiculous practice of alerting operators to spot checks. The review also urged the streamlining and strengthening of the regulator.

If one does a simple online search many of the big ‘for profit’ aged care providers are named in relation to such abuse, neglect and sub-standard health care allegations.

Now in May 2018 the Tax Justice Network^[1]  is looking at aged care provision from another angle. One which shows that the budgetary meanness which sees these big companies expect elderly residents to remain in sodden incontinence pads or live-off meagre meal rations occurs in spite of the millions in profit made on the back of billions in taxpayer funding of the age care sector.

It has released A Tax Justice Network – Australia Report, TAX AVOIDANCE BY FOR-PROFIT AGED CARE COMPANIES: PROFIT SHIFTING ON PUBLIC FUNDS.

Sadly, this report only confirms the fact that corporate greed runs rampant through all major aspects of Australian life, including aged care.

Executive Summary, Background, p.5:

Older people are a growing proportion of Australia’s population; in 2016, 15% (one in seven) Australians were aged 65 years or older. By 2056 this percentage is expected to grow to 22% (8.7 million).1 The need for aged care services is increasing. Between 2015– 2016 almost 214,000 people entered aged care in Australia. On average, older people in Australia spend three years in permanent residential care, just over two years in home care, and one and a half months in respite care.2 The Australian tax payer, via the Commonwealth Government contributes around 75% of the expenditure in aged care in Australia, which is around 96% of the total funding on aged care from Commonwealth and State Governments. Government recurrent spending on aged care services in Australia was $17.4 billion Australian dollars (AUD) in 2016- 2017, with residential aged care services accounting for 69.3% ($12.1 billion AUD).3 Some of this funding is provided as subsidies to aged care provider companies including those that operate for profit. In 2018 the Australian Nursing and Midwifery Federation (ANMF), Australia’s largest national professional and industrial nursing and midwifery organisation with over 268,500 members, commissioned the Tax Justice Network - Australia to analyse possible tax avoidance by for-profit aged care companies and to provide recommendations for improving transparency on Government spending on for-profit aged care.

Key points from the report

* By number of beds, not-for-profit providers are the largest aged care provider group in Australia (52% in 2013-2014), however there has been a rapid growth in the size and spread of for-profit companies; Bupa, Opal, Regis and Estia are the largest aged care providers nationally. If Japara and Allity are included, these 6 for-profit companies operate over 20% of residential aged care beds in Australia.

* In the most recent year (mostly the 2017 financial year) the six largest for-profit companies were given over $2.17 billion AUD via government subsidies. This was 72% of their total revenue of over $3 billion. These companies also reported profits of $210 million AUD (2016-2018).

* Companies can use various accounting methods to avoid paying tax. One method is when a company links (staples) two or more businesses (securities) they own together, each security is treated separately for tax purposes to reduce the amount of tax the company has to pay. Aged care companies are known to use this method as well as other tax avoiding practices. Another practice is by “renting” their aged care homes from themselves (one security rents to another) or by providing loans between securities and shareholders.

* The six largest for-profit aged care providers have enormous incomes and profits:

* The largest company, BUPA, had almost $7.5 billion in total income in Australia (2015-16) but paid only $105 million in tax on a taxable income of only $352 million.

* BUPA’s Australian aged care business made over $663 million in 2017 and over 70% ($468 million) of this was from government funding.

* Funding from government and resident fees increased in 2017, but BUPA paid almost $3 million less to their employees and suppliers.

* The second largest, Opal, had total income of $527.2 million in 2015-16 but paid only $2.4 million in tax on a taxable income of only $7.9 million.

* 76% ($441 million) was from government funding in 2016.

* Allity had total income of $315.6 million in 2015-16 and paid no tax.

* 67% ($224 million) of Allity’s revenue was from government funding in 2016-17.

* Regis, Estia, and Japara are listed on the Australian Securities Exchange (ASX) but appear to be using methods to reduce the amount of tax they pay while earning large profits from over $1 billion of government subsidies.

* Family owned aged care companies (Arcare, TriCare, and Signature) receive between $42-$160 million each in annual government subsidies but provide very little public information on their operations and financial performance and may use accounting methods to avoid paying tax.

 * (All figures quoted above are in AUD)

* The Australian Government and the Federal Opposition (the Australian Labor Party) have proposed several ways to fix the problems with companies avoiding tax by using trust structures and other methods but there are still loopholes.

* It is difficult to get a detailed and complete picture of the full extent to which these heavily subsidised aged care companies are avoiding paying as much tax as they should, because Australian law is not currently strong enough to ensure that their financial records and accounting practices are publicly available and fully transparent.

Conclusion

The six largest for-profit aged care providers in Australia received over $2.17 billion AUD in annual tax payer funded subsidies which provided after tax profits of $210 million AUD. The actual operating profits were much larger. These providers only paid around $154 million AUD in tax in 2015-16. Companies that receive millions of tax payer dollars via Australian government subsidies must be required by law to meet higher standards of transparency in financial reports and be publicly accountable. The report calls upon the Government, Opposition, and cross-bench Senators to work together to make laws to stop aged care providers from avoiding the taxes they should pay and provide clear records of their business dealings.

The Tax Justice Network – Australia strongly supports recent government legislation that has been introduced to close loopholes in the Multinational Anti-Avoidance Law and government reforms to stapled structures. However, there is still a need for additional transparency measures. The Tax Justice Network – Australia also strongly supports a policy proposed by the Australian Labor Party to introduce minimum taxation of discretionary trusts. These reform measures are examined in more detail by this report in the section: Current Reform Measures.

This analysis of tax payments and corporate structures of the largest for-profit aged care companies provides clear evidence that simple common-sense reforms are needed immediately to restore integrity to the tax system and to ensure public accountability on billions of dollars in government spending.

RECOMMENDATIONS FROM THE REPORT

Any company that receives Commonwealth funds over $10 million in any year must file complete audited annual financial statements with Australian Securities and Investments Commission (ASIC) in full compliance with all Australian Accounting Standards and not be eligible for Reduced Disclosure Requirements. Public and private companies must fully disclose all transactions between trusts or similar parties that are part of stapled structures or similar corporate structures where most or all income is earned from a related party and where operating income is substantially reduced by lease and/or finance payments to related parties with beneficial tax treatment.

Australia’s Largest For-Profit Aged Care Companies

In Australia, non-profit providers collectively operate a majority of residential aged care beds. However, the market share of large for-profit providers continues to grow rapidly. Likewise, the influence of for profit providers on shaping government policy and influencing broader trends in the aged care sector has never been greater. Ranked by the number of government allocated residential aged care places (beds) in 2017, the six largest for-profit aged care companies in Australia are; Bupa, Opal, Regis, Estia, Japara, and Allity. Combined, they operate over 20% of all residential aged care beds in the country. These companies continue to expand market share through new developments and acquisitions. These companies are also expanding to provide more retirement living and home care services, which allow access to additional government funding. In the most recent financial year (2016-2017), these six for-profit aged care companies combined received over $2.17 billion in government subsidies.4 This made up 72% of their combined total revenue of over $3 billion.5……

COMPANY SNAPSHOT

Bupa: A United Kingdom-based mutual insurance company with global operations including aged care services. Australia is Bupa’s largest and most profitable market.

Regis, Estia, and Japara: Public aged care companies listed on the ASX.

Opal: A private aged care company owned by subsidiaries of two listed companies, AMP Capital and Singapore-based G.K. Goh.

Allity: controlled by Archer Capital, an Australian private equity firm with large foreign pension fund investors.

Arcare, TriCare and Signature (formerly Innovative Care): three family-owned, for-profit aged care companies.

NOTE:

1. The Tax Justice Network - Australia is the Australian branch of the Tax Justice Network (TJN) and the Global Alliance for Tax Justice. TJN is an independent organisation launched in the British Houses of Parliament in March 2003. It is dedicated to high-level research, analysis and advocacy in the field of tax and regulation. TJN works to map, analyse and explain the role of taxation and the harmful impacts of tax evasion, tax avoidance, tax competition and tax havens. TJN’s objective is to encourage reform at the global and national levels.

Membership of the Network can be found here.

Is living in aged care in Australia bad for your mental health?

An estimated 10–15% of older Australians who live in the community experience anxiety or depression (Haralambous et al. 2009). However, research has shown that certain sub-groups of the older population are at higher risk of experiencing poor mental health. For example, just over half (52% or 86,736) of all permanent aged care residents at 30 June 2012 had mild, moderate or major symptoms of depression when they were last appraised (AIHW 2013). [Australian Government, Australian Institute of Health and Welfare, Australia’s welfare 2015]

The Sydney Morning Herald, 7 January 2017:

Tens of thousands of elderly Australians are being  denied effective public health treatments because they live in nursing homes, with experts labelling it a "disgrace" and "blatantly discriminatory".

A Fairfax Media investigation has revealed the mental health of aged-care residents suffers as a result of widespread neglect that legal and health experts attribute in large part to a   "ridiculous" Medicare rule.

Under the rule almost all nursing home residents are denied GP mental health treatment plans and associated psychological therapies provided to other Australians under the Better Access Medicare program, because the government deems residents not to be patients "in the community".

Despite extreme rates of mental illness in nursing homes – with about 82,000 of 176,000 residents estimated to suffer a mental illness (excluding dementia) or significant mental distress – the Turnbull government reaffirmed the regulatory exclusion late last year.

While the government says its funding mechanism assesses depressed residents' care needs, a Fairfax Media investigation has discovered the homes almost never pay for clinical mental health treatments and experts say the government has neither legally compelled nor adequately funded them to do so.

Audits by Sydney and Deakin universities have repeatedly found that fewer than 2 per cent of residents suffering depression have received psychological treatments, such as cognitive-behavioural therapy,  that are clinically recommended for most depression experienced in the aged-care setting…..

Royal Australian College of GPs president and University of Tasmania clinical professor Bastian Seidel agreed the denial of treatment was "systematic" because "the data is out there" and he called for the removal of the Medicare exclusion.

Researchers have found only about half of all residents with depression receive treatment of any kind, whether from psychologists or other clinicians, and that almost all of those are put on antidepressants by GPs, despite their use in the elderly being linked to serious adverse effects, including falls and fractures.

Stigmatising attitudes and ignorance about mental healthcare have also been found to be widespread among nursing home staff, with unpublished Swinburne University survey data suggesting staff commonly dismiss depressed residents as "attention seeking" and lack basic knowledge about mental illness.

While many residents arrive in homes with depression or other mental disorders, others struggle mentally due to challenges experienced in care, such as chronic pain, disabling and terminal medical conditions, progressive loss of brain function and the loss of social role and sense of identity.

"There are commonly acute adjustment disorders … [involving] bereavement, grief, loss," said Adelaide older persons GP Johanna Kilmartin, who described the Medicare restriction as ridiculous.

"You lose your family home [for] … one tiny little room … so you've lost all your material possessions; you've lost your health, because that's why you've moved in; often you've lost your spouse as well.

"This is when you need [psychological help] … [but] we've got the opposite"……

A spokesman for the Department of Health said while Commonwealth-funded residents – understood to be all or almost all aged-care residents – were not eligible for Better Access services, the government's aged-care funding instrument "assesses residents' care needs, including in relation to depression".

He said approved homes were required to "facilitate … access" for residents to health practitioners of their choosing and gave as an example "arranging transport".

But the dean and head of the University of South Australia's law school Wendy Lacey slammed the "weasel words" of the Aged Care Act's care "principles", saying there was "a complete absence of any positive and mandatory legal obligation on the part of facilities to take proactive measures to promote mental health and wellbeing of their residents".

There was "no legal obligation on the residential care provider to pay" for mental health services, and the "current exemptions" –  arising from the Aged Care Act and Medicare regulation – were "a blatant denial of human rights involving discrimination on the basis of age and infirmity".

Australian Catholic University senior research fellow Tanya Davison, whose research has found that half of all clinical cases of depression received no treatment of any kind, cited funding "that runs out very quickly" as among contributing factors to the "critically low" psychological therapy levels…..

The Conversation, 28 July 2015:

More than half (52%) of aged care residents have symptoms of depression, compared with 10-15% of older people living in the community. As well as feelings of sadness and low mood, aged care residents with depression feel uninterested in activities, hopeless about the future, guilty about the past and may desire death.

Some actively contemplate taking their own lives. The prevalence rate of suicidal thoughts in residential aged care settings can be as high as 46%. This is more than three times the rate found in older adults who are housebound but in the community.

People entering residential aged care facilities are, on average, older than those living in the community. They have more complex care needs due to physical and cognitive difficulties. They may also have difficulties adjusting to their loss of independence and routine. These factors all increase their risk of depression and suicidal ideation.

However, mental illness often remains undetected among aged care residents.

There are several reasons for this. People living in residential aged care usually have complex care needs, making the identification of depression difficult, as the emotional symptoms become confused with those of other conditions. Older people are also less likely than younger people to recognise their own symptoms, often attributing them to normal ageing.

Further, although facility-based carers are in a position to act as informants, they often lack the training to detect symptoms of depression and do not routinely screen for suicide ideation.

Depression is a manageable condition and the symptoms can be improved or managed through therapy and medication. Medications are effective but are often associated with side effects, and for older adults may not be recommended alongside some other medications and conditions.

Yet, when residents are recognised to have symptoms of depression, they are often only prescribed medications (particularly antidepressants) despite the effectiveness of non-medication approaches. Research shows interventions such as cognitive behavioural therapy (a talk therapy that addresses how you think and act) are at least equally effective as anti-depressants for improving late-life depression.

BACKGROUND

National Ageing Research Institute, Depression in older age: A scoping study, Final Report, September 2009:

4.1 Depression and anxiety in older people

It is a common misconception that depression is a normal part of ageing, but the evidence shows that multiple health problems often account for any initial association between depression and older age (Baldwin, 2008; Baldwin, Chiu, Katona, & Graham, 2002). Depression is essentially the same disorder across the lifespan, although certain symptoms are accentuated and others are suppressed in older people. For example, older people with depression typically report more physical symptoms and less sadness compared to younger people with depression (Baldwin, 2008; Chiu, Tam & Chiu, 2008). Additionally, psychotic symptoms, melancholia, insomnia, hypochondriasis, and subjective memory complaints are more likely to occur in older people with depression compared to younger people with depression (Baldwin, 2008; Baldwin et al., 2002). A recent review found that when confounding variables are controlled (for example, age at study entry), remission rates of depression in patients in late-life are not different from those in midlife, although relapse rates appear higher in older people (Mitchell & Subramaniam, 2005).

Anxiety disorders are also common among older people. However, research in this area is less compared to research undertaken in other mental disorders in older people, such as depression (Wetherell, Maser, & van Balkom, 2005). Of the anxiety disorders, phobic disorders and generalised anxiety disorder (GAD) are the two most common in older people (Beyer, 2004; Bryant et al., 2008; Rodda, Boyce, & Walker, 2008). There has been a certain amount of clinical interest in post-traumatic stress disorder (PTSD), because the survivors of the Second World War and the Holocaust are now well into old age. Moreover, Vietnam Veterans are also approaching old age with well-documented high levels of psychopathology (Owens, Baker, Kasckow, Ciesla, & Mohamed, 2005) that can also have serious effects on the mental health of family members (Galovskia & Lyons, 2003). Prevalence data on PTSD, however, are very limited (Sadavoy, 1997). American studies of Holocaust survivors have found that up to 46% meet criteria for PTSD (Sadavoy, 1997). Weintraub and Ruskin (1999)’s review emphasises the similarities between PTSD in older and younger groups. Other authors have disputed this, and further research is required to establish how different the presentation of PTSD is in older adults from that in younger people.

A recent Australian study found that 11.6% of men and 8.6% of women aged over 65 reported re-experiencing symptoms associated with past events (DSM IV criteria), and concluded that quality of life may be significantly affected in this group (Creamer & Parslow, 2008). This study highlights some of the difficulties in the application of the DSM IV criteria to older adults.

Research on interventions for older people with PTSD is very limited indeed. A recent review of assessment and treatment of PTSD in older combat veterans identified only five studies of psychotherapeutic intervention (Owens et al., 2005). All of these were case studies. A literature search carried out for this review did not identify any randomised controlled trials of psychological intervention for older people diagnosed with PTSD.

Comorbidity of depression and anxiety disorders is highly prevalent (Beekman et al., 2000). A community-based study in the Netherlands found 47.5% of older people with major depressive disorders also met criteria for anxiety disorders, whereas 26.1% of those with anxiety disorders also met criteria for major depressive disorders (Beekman et al., 2000). Mixed anxiety and depressive disorders (where symptoms of both anxiety and depression do not reach diagnostic criteria for either disorder) also frequently occur in older people (Chiu et al., 2008; Rodda et al., 2008). Older people with depression have a 35% lifetime and 23% current prevalence of a co-morbid anxiety disorder (Beyer, 2004). Furthermore, when anxiety symptoms first occur in a person over 60 years of age with no history of anxiety, it generally suggests underlying depression (Baldwin, 2008; Chiu et al., 2008). Indeed, it is quite uncommon that people develop late-onset anxiety disorders for the first time in later life (Chiu et al., 2008), although there are researchers who disagree with this (Wetherell, Maser et al., 2005). Older people with co-morbid depression and anxiety typically have more severe depressive symptoms, an increased likelihood of suicide ideation, lower social functioning (Beyer, 2004; Rodda et al., 2008) and poorer outcome (Schoevers, Beekman, Deeg, Jonker, & van Tilburg, 2003)…..

The 2007 National Survey of Mental Health and Wellbeing found that the 12-month prevalence for depression and anxiety was 2% and 5%, respectively for older people living in private dwellings (Australian Bureau of beyondblue depression in older age: a scoping study. Final Report - National Ageing Research Institute (NARI), September 2009 - 13 - Statistics, 2008). Another Australian study found that the prevalence of depression was 8.2% among a sample of 22,252 community-dwelling older people (Pirkis et al., 2009). However, the prevalence rate is much higher in residential aged care facilities and a recent Australian study found that 34.7% of aged care residents suffered from depression (Snowdon & Fleming, 2008).

Turnbull Government fails to think through aged care funding cuts

Another example of the monumental cock-up that that is the Australian Federal Government under Malcolm Turnbull & Co.

Australian Financial Review, 6 September 2016:

The Turnbull government has agreed to review $1.2 billion in aged care cuts after the sector presented modelling showing the effect would be much greater than anticipated. 

As ASX-listed providers blamed the funding squeeze for a 30 per cent drop in the value of their shares, Aged & Community Services Australia president Paul Sadler said modelling revealed the cuts would reduce support per resident per year by 11 per cent, or between $6655 and $18,000. 

He told The Australian Financial Review that the government had indicated it was willing to talk about alternative ways for find the $1.2 billion in savings to what is known as the "aged care funding instrument" announced in the May federal budget. Labor had already given a similar commitment. "The government has started the process of talking to the sector about alternative approaches," Mr Sadler said.

Aged & Community Services Australia is among a number of groups and representatives that have told the government there are better ways to achieve the savings. 

The government concession comes as the trio of listed companies operating in the aged care space – Estia Health, Regis Healthcare and Japara Healthcare – experienced a sharemarket slump that they said was driven by restrictions on what they can charge residents.

The federal Department of Health clarified last Friday that providers could not charge building refurbishment or capital replacement fees on top of existing accommodation charges. 

"It's like you or I paying rent and then being charged extra to fund the cost of maintaining the building in the future," said Grant Corderoy of Stewart Brown, an accountancy firm that conducts a quarterly survey of aged care financial performance……

Aged care funding is complex.

Costs are split into two parts: healthcare and accommodation.

In the first category, funding is largely provided per resident by the federal government based the level of support required according to health needs.

Separately, accommodation is paid for via a refundable loan (paid by the resident), an equivalent daily payment (which is either covered by the government or the resident, depending on capacity to pay) or a combination of both.

There has been bipartisan support in Canberra to deregulate the accommodation part of the equation.

While the amount that can be charged for accommodation has a regulator to monitor pricing levels, residents can agree to pay extra for higher standards of food or services; a glass of wine in the evening or massage therapy, for example.

Some providers have added levies of up to $18 a day for building maintenance and building replacement.

But last Friday the department said these charges should be included into the base accommodation pricing – they could not be charged as "added extras".

The end result is a potential loss of revenue per resident of $4000 to $5000 a year depending on the extent of the additional charge……

TO WHOM IT MAY CONCERN: Uniting Care Australia calls for halt to funding cuts targeting fail older people

United Care of Australia calls on the government of the day (whomever that may be) to halt funding cuts.....

Australian Federal Election 2016: Abbott shafted the frail aged in New South Wales, Turnbull ignores their predicament and now Baird has turned his back

The profits of aged care homes surged 40 per cent in the past year as operators cut hours of nursing care while claiming higher payments from the federal government for servicing more of the most frail patients. The earnings boom in the sector comes after the government introduced widespread reforms of aged care in 2014, including deregulating fees and lifting restrictions on the accommodation bond that nursing homes can levy on residents. [The Sydney Morning Herald, 1 January 2016]

In 2014 then Prime Minister Tony Abbott amended the C’wealth Aged Care Act 1997 with the Aged Care (Living Longer Living Better) Act 2013.

The amendments impacted on the requirement under s104 of the NSW Public Health Act 2010 to have a registered nurse on duty at all times in a nursing home.  

The Baird Government initially grandfathered its Public Health Act until December 2015 and then awaited a report by the NSW Legislative Council General Purpose Standing Committee No. 3’s parliamentary inquiry established on 25 June 2015.

On 29 October 2015 the Committee’s Final Report was tabled with the following recommendation:

On Friday 29 April 2016 at 3.15pm the NSW Baird Coalition Government responded to the Final Report’s 17 recommendations by washing its hands of any responsibility for staffing levels NSW nursing homes:

So three days before the 2016-17 federal budget details are revealed, possibly less than 32 days until the federal government enters caretaker mode ahead of a 2 July 2016 double dissolution federal election, and at the end of a working week, this Liberal-Nationals state government announces that it is very willing to place the lives of every frail aged resident in New South Wales nursing homes at significant risk.

Perhaps he and his government are hoping that the media will quickly lose interest and, that older voters and their families will forget that they will now be playing what could possibly be a cruel game of Russian roulette if they decide to spend their remaining years in aged care.

Failure to maintain staffing numbers and nursing care levels in Australian aged care facilities is a disgrace

In June 1999, a little over a year into the first term of the Howard Coalition Government,  there were an estimated 132,420 older Australians in residential aged care facilities, with 61 per cent having “high care” dependency status.  

Between 1994 and 1999 there was a 13.9% decrease in the number of registered nurses and a 26.0% decrease in the number of enrolled nurses, so that by 1999 there were 19,517 registered nurses employed full-time in residential aged care facilities and 13,818 enrolled nurses.

A decade later and the percentage of registered nurses working in residential aged care facilities fell from 11 per cent (or 18,313 individuals) in 2003 to 8 per cent (or 16,431 individuals) in 2009 and the number of enrolled nurses fell from 29 per cent (or 12,933) to 21 per cent (or 10,030) in 2009.

In 2011 the number of permanent residents in aged care numbered an est. 165,032 people.

By 2012 the percentage of the residential aged care workforce being registered nurses or enrolled nurses working in residential aged care had only risen to 14.7 per cent (or 13,939 individuals) and 11.6 percent (or 10,999 individuals) respectively, which is an actual fall in total numbers of RNs & ENs in the aged care workforce.

During the course of the 2013–14 financial year 270,559 people were admitted to age care facilities either on a permanent or respite basis. Nationally in March 2014 registered nurses comprised 15.3% of the residential aged care workforce and enrolled nurses made up 21.9% [Aged and Community Services NSW & ACT].  By June 2014 the “high care” dependency level of aged care residents had risen to 83 percent.

However, in 2014 the Abbott Government changed the federal Aged Care Act 1997 in such a way that allowed residential aged care operators to reduce the number of registered nurses employed in their nursing homes, as well as deregulating fees charged and accommodation bonds levied. 

In response the NSW Government effectively grandfathers facilities subject to the current NSW Requirements for a period of 18 months in order to block any moves to reduce state legislated provision of a minimum of one registered nurse on duty 24/7 in nursing homes containing “high care” beds.  This reprieve appears to come to an end around February this year but the state government’s formal response to the NSW Legislative Council report it ordered is not due until 29 April.

Meanwhile The Sydney Morning Herald reported on 1 January 2016 that: The profits of aged care homes surged 40 per cent in the past year as operators cut hours of nursing care while claiming higher payments from the federal government for servicing more of the most frail patients. The earnings boom in the sector comes after the government introduced widespread reforms of aged care in 2014…Yet while nursing homes report they are looking after more needy residents, the time spent caring for them declined by 7 per cent over the past year. In 2015, hours by care staff (nurses, care assistants and therapists) fell from 42.71 hours per fortnight to 39.80 hours per fortnight. At 2.8 hours a day, the average is well below the minimum of 4.5 hours per day of nursing care mandated in the US, said Lynda Saltarelli from the Aged Care Crisis advocacy group."Australia has no recommended levels for staffing," she said. "Over half of all nursing homes in Australia have nursing levels so low that most residents suffer harm."

Australia currently has about 2,800 residential aged care facilities providing care to more than 160,000 elderly people. Over the next ten years, the number of residents is projected to reach more than 250,000 and the highest area of growth will be among residents aged 95 or over. During that same ten-year period the number of registered nurses and enrolled nurses employed in aged care facilities is expected to further decline, according to Health Workforce Australia.

Prime Minister Malcolm Bligh Turnbull and his Cabinet need to take a long hard look at this mess and use legislation and regulations to raise these staffing levels and hours of care received before the next federal election.

The issue is not going unnoticed by voters……

Letter to the Editor, The Age 3 January 2016:

Low nursing levels, low level of care

It is outrageous that nursing homes do not have recommended staffing levels. Elderly people with dementia or Alzheimer's disease – and who, in some cases, have paid bonds of hundreds of thousands of dollars as well as continuing monthly payments – deserve the best possible care. By law, childcare organisations have staff ratios yet children are able to learn and notify carers if they are in pain, hungry or need to be toileted. Dementia patients cannot do this and will only become more in need of care as their condition worsens. Thankfully my mother, who has late-stage Alzheimer's disease, is in a wonderful facility. However, in my search for a good home, I saw many where up to 15 dementia patients were cared for by one staff member. With an ageing society, the number of people entering nursing homes will increase, profits will continue to soar and our most vulnerable citizens will suffer. Staff ratios must be put in place.

Annie Jones, West Melbourne [my red bolding]