Interview: Nick Ryan: Aged care must be about the lived experience

We speak with Nick Ryan, Chief Executive Officer Lutheran Aged Care and former Chief Executive of the Australian Aged Care Quality Agency on the recommendations of the Royal Commission into Aged Care Quality and Safety and the implications for boards and governance advisers.

Aged care is a personal experience. This is the singular principle that runs through the report and recommendations of the Royal Commission into Aged Care Quality and Safety. The reform must be centred around people who receive care.  Nick Ryan, CEO of Lutheran Services, and former CEO of the Australian Aged Care Quality Agency says the real measure of aged care reform should be that whatever occurs in the design of the system — in the funding for the system, in the legislation, all the way through to a knock on the door for homecare services — is not about the provider. It must be about older Australians living their best possible quality of life. While this should be second nature for the sector, the challenges have been many as was made clear in the report of the royal commission in February 2021.

‘If you look at the history of the aged care industry in the last 20 or so years, initially aged care was a quasi-hospital model. And a bit like hospitals were, say 30 or 40 years ago, the focus was on the delivery of good clinical care. Of course, it involved the patient, but it was fundamentally about the quality and the safety of the clinical input.’ But, Mr Ryan says, hospitals have moved on significantly to notions of the patient journey. ‘In obstetrics for instance, it is now seen as the mother’s and baby’s birthing experience and not just a clinical experience. And so, we have lots of examples in the broader healthcare sector and certainly in the disabilities sector that show that the focus should never just be on the people funded to deliver services. But — and it sounds almost ridiculous to have to say it — it is really about the lived experience of the people for whom the services have been designed and to whom they are actually delivered.’

The real measure of aged care reform should be that whatever occurs in the design of the system … is not about the provider. It must be about older Australians living their best possible quality of life.

Shift from provider focus to consumer voice

‘It is not that the aged care sector was particularly enamoured of a provider-centred approach but inch by inch through regulation, through history, through practice, through culture, the industry was overly locked into a provider-focused approach. That is not to say that every provider has always been like that. But under the older aged care standards, that we used for over twenty years, providing there were not a lot of complaints, the views of the residents and their relatives were kind of peripheral.’ Now however, in the establishment of the new Aged Care Quality Standards, the underpinning is first and foremost about the dignity and the choice and control of the older person. The new Standards were piloted while Mr Ryan was CEO of the Australian Aged Care Quality Agency, and have been in effect for almost two years, ‘This is about aged care providers providing older Australians with services so that they lived their life, rather than they live in our residential homes and put up with what we provide or the way we do things around here.’

But, while the focus in aged care reform for some time now has been around consumers or residents or older people front and centre, once you begin to unpack the design of care and the delivery of care, there is a great deal of work to be done, says Mr Ryan. ‘And the royal commission clearly picked up this approach on the experience, the care and the choice, the transparency of information, the quality of feedback from our residents and their representatives in the design and the broader delivery of care.’

The consumer voice is the thread running through the recommendation. Mr Ryan feels that the problem with the approach to consumer voice is that it is often deemed to be a tick and flick customer feedback model. ‘What we are interested in is a far more fundamental notion of co-design. Rather than us designing services which older people will have to fit into, what we are interested in is to work with older Australians and their families to say what does your best possible life look like whilst you live in the community and what will be the best possible life experience, if you were to move into residential aged care? And then, and only then, design new services.’ Co-design, Mr Ryan says, means the provider must listen to older people who articulate in many different ways their best possible life. ‘And then we have to say what are well designed, efficient, respectful ways in which we can support and enhance an older person’s quality of life, not just provide a ‘service’; that’s the shift.’

The royal commission has set down a clear set of principles for reform — a new act of parliament, new ways to fund the industry, greater transparency, greater access to information.

Greater resources and independence for the regulators

This all seems intuitive and instinctive and the natural core of the care and service that the sector should provide. So, what went wrong that we are at this point where the sector is seen to be in crisis, and a royal commission had to be set up to investigate the failures and recommend sweeping reforms and repair?

‘If you talk about a crisis, firstly you would need to look at it in terms of regulations. So, the regulator — of which I was CEO for five years — had to administer a scheme that was narrow in its scope and its resources. The royal commission has now said that whoever is the regulator (currently the Aged Care Quality and Safety Commission), should have greater resources and greater powers.’

One of the key areas that two Commissioners differed on was the shape and form of the new regulator. Commissioner Pagone calls for an independent regulator while Commissioner Briggs says it should stay as a department reporting to a Minister. ‘Independence is fundamentally important because the decisions that a regulator makes need to be free of any risk of political interference. I think what Commissioner Pagone was talking about was, that not just the regulator but the agencies responsible for legislation, funding, regulation etc should be an entirely separate Commission, independent of direct ministerial oversight. The funding for such an entity in a few years will be $30 billion. Now Commissioner Briggs, being an experienced public servant says, $30 billion of public expenditure should have ministerial accountability attached to it. But both Commissioners agree on the statutory independence of the regulator.’ In the end, Mr Ryan reflects it is not about which model you adopt but that you make sure with whichever model you adopt works for older Australians.

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Clear governance principles for reform

The royal commission has set down a clear set of principles for reform — a new act of parliament, new ways to fund the industry, greater transparency, greater access to information. ‘I think at some stage we need to cut to the bone and for those interested in governance in aged care I am afraid the recommendations are rather severe.’

If you look at the new Aged Care Standards, the centrality of Standard 1 is around the consumer or the resident. That, Mr Ryan says, is one bookmark. The other is governance. ‘We put a much greater emphasis on corporate governance in the development of the new standards. That comes from understanding that governance underpins and imbibes the culture, the prioritisation, and performance of any organisation. Under the new standards, the whole organisation has to be accredited from the boardroom to the bedside.’

The royal commission had strong recommendations on how this could be achieved. Firstly, the report says, ‘in summary the new regulatory system needs to be much more rigorous in only letting into the system those providers that can demonstrate their suitability and capacity to deliver high quality care.’ This Mr Ryan points out is not just about compliant care but high-quality care. It goes on to say that the system must be ‘more vigilant and energetic in assessing the performance of the providers and more determined to remove from the system providers that are either unable or unwilling to deliver consistently high quality and safe care.’

Recommendation 89 is on leadership responsibilities and accountabilities for senior management and boards. You will need to have professional qualifications or high-level experience

Leadership and accountability

‘Recommendation 89 is on leadership responsibilities and accountabilities for senior management and boards. You will need to have professional qualifications or high-level experience. There needs to be regular performance appraisals, significantly better staff training, professional development and team building.’ The new governance standard is to have members of the governing body possess between them skills, experience and knowledge of governance responsibilities including care governance, systems, structures, processes for ensuring the safety and high quality of the care delivered by the provider. ‘So, this is not putting the obligation just on the nurse in the residential aged care facility, but the people who sit on the board. They should have a care governance committee. They should receive regular feedback. There should be better complaint systems, better risk management practices. And it calls for a test annually on behalf of the members of the governing body that they have satisfied themselves that the provider has all of that in place. So, what they are saying here is that it is not the onus on the regulator to come and find non-compliance. It is that the board or the governance group of the provider attests annually. They have to put their hand up and therefore they are more liable if they don’t live up to that attestation.’

Recommendation 97 says that the Commissioner ie, the regulator, could have a power to authorise in writing an officer to enter and remain on the premises at all reasonable times without warrant or consent, and a power to enter the premises at other times if the regulator reasonably believes there is an immediate and severe risk to the safety, health and well-being of people receiving care. This is the tough part Mr Ryan says. ‘They will have full access to all the documents, goods and other property of the care provider and powers to inspect, examine, make copies or take extracts from any copy. The onus of proof and the laws of evidence and investigation that underpin policing is stronger than for most police forces in Australia. The royal commissioners are not mucking around on governance and compliance. They are also talking about civil penalties for contravention of general duty. They are saying not only the organisation as a whole will be held liable, but directors and officers can be personally sued and prosecuted for breaches. We have seen nothing like this in Australian aged care before.’

Mr Ryan asks the question here, do the members of the governance group or board have any idea what the day-to-day experience of the older person or resident is? ‘One of the things that we do at Lutheran Services is, our board members go and spend an entire night from before dinner to after breakfast the following morning and sleep in the residential aged care facility. They are there to wonder what it would be like to go to sleep there every night and wake up every morning. And they only have five questions to answer. What do they see? What do they hear? What do they smell? What do they taste? What do they touch? There is a much greater onus on aged care providers to be radically interested in the lived experience.’

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