Aged care in Australia is at a crisis point.
In 2021, the Royal Commission into Aged Care Quality and Safety released its final report, which contained 148 recommendations to build a stronger, more supported system.
Yet the sector continues to struggle, something that's particularly felt by the estimated 191,000 Australians who are in residential aged care.
Last month, separate government data reported that the sector lost almost $440 million in the first quarter of the 2023 financial year, which equals a loss of $27.90 per resident every day.
These inefficiencies could be exposing residents to unnecessary harm. For example, more than 5,000 aged care residents have died from COVID-19 since the start of the pandemic, according to government data.
Recent ideas to remedy the crisis have ranged from relying on independent contractors, something that was backed by the Productivity Commission in October, to increasing taxes to provide more funding for the sector.
However, some argue the aged care sector's problems run deeper than a lack of resources.
"This is not a good service model," Mike Rungie, the director of the Global Centre for Modern Ageing and a former aged care CEO, tells ABC RN's Big Ideas.
"We talk about how you do transformation, but it's a very different process that starts with a blank sheet and designs something from the point of view of a good frail life."
One idea would be to shift to a more integrated approach to aged care, such as co-design — a model that includes the input of older people in the development of an aged care facility, ranging from the layout of a facility to the day-to-day activities of residents.
This would prioritise "research and innovation that involves co-design with older people, their families and the aged care workforce".
Institutionalised care
Peter Bragge says Australia's aged care system is not currently centred around the experience of the residents.
The director of health programs at Monash University's Sustainable Development Institute's Behaviour Works describes the system as "institutionalised care".
"Why does everyone suddenly have to get up at nine in the morning and be dressed and have breakfast? Just because they're in an institution?" he says.
"Why can't someone who's in their 80s have an extra bowl of ice cream, even though they've got diabetes?"
Others have also challenged the current way of doing things.
In 2015, surgeon and author of Being Mortal Atul Gawande told the ABC the current model left residents feeling "like they're in prison".
Researchers have often reported residents of Australia's aged care feel isolated and lack autonomy.
"The most common complaint, what you hear them say over and over is, 'When do I get to go home,'" Gawande says.
"And you realise, 'What is home?' And home is ultimately a place where you get to make the choices about the risks you want to take."
Dr Rungie agrees.
"What residential aged care does is strip off all those things you did the day you move in and doesn't replace them with anything else, except a bit of entertainment."
Learning from others
Another problem with the current approach to aged care is that it suggests older people are no longer able to contribute to society.
Dr Bragge says this idea can have negative implications for older people — and the rest of us.
"If older people are always represented as frail, unable to move, then they [come] to think of that as their future."
Studies have suggested a negative outlook on ageing could influence quality of life. In 2016, researchers with Cambridge University reported those who associated being elderly as negative were less inclined to wish to be alive and old.
The good news is that this powerful influence can swing both ways.
Dr Rungie points to places like Japan's Okinawa, Italy's Sardinia and Costa Rica's Nicoya Peninsula where many residents have positive expectations of ageing and life expectancies are higher than average.
Research has long considered why these communities have longer life expectancies, with researchers finding nine common factors, such as having purpose, reducing stress and "moving naturally".
According to Ngaire Kerse, the Joyce Cook Chair in Ageing Well at the University of Auckland, this often reflects the local social expectations.
"In those … areas, the social patterning is to always be active, they always see that people who are 90 still working, still walking up [steep hills]."
Professor Kerse says Australian society could learn from these communities, to change our thinking to see older people as valuable and give them the opportunity to make a contribution.
"But our society, the way it's structured, constrains them from doing that, because there's no expectation from society that they have any value."
Health is wealth
While addressing Australia's approach towards aged care and older Australians is important, there are also other factors that influence how well we age.
Since 2010, Professor Kerse has been studying the experience of life in advanced age in New Zealand, speaking to both Māori and non-Māori women.
She made a number of discoveries in her research, including that many older New Zealand women are still active in their community and that anyone's health outlook can improve or worsen as they age.
"We've got to let our older people in their 80s recover and regain their function and offer them opportunities for rehabilitation," she says.
She also found differences, including the influence of access to health and social care for non-Māori women.
"People have had significant disadvantages. They've not been offered opportunities, they've not had the opportunity to have a stable job and build up their own housing, and maintain their functions," she says.
She says this shows that many parts of someone's life impact their experience of ageing.
Factors like race and socio-economic status can have a significant impact on someone's experience in old age.
For example, the Australian Institute of Health and Welfare found that only 20 per cent of people using permanent residential aged care were from a culturally and linguistically diverse background.
And a US paper concluded in 2020 that higher socio-economic status was related to greater access to health care and better health outcomes as an older person.
Professor Kerse would like to see more older people included in the conversation about improving aged care.
"We should be having discussions about it in the context of our ageing."
RN in your inbox
Get more stories that go beyond the news cycle with our weekly newsletter.
