Care for New Zealand’s seniors branded a human rights crisis

Saturday, 20 April 2024

A United Nations expert and New Zealand’s Disability Rights Commissioner say access to care for older Kiwis has become a human rights issue. LOUISA STEYL looks at what needs to change.

New Zealand’s health and disability system is upside down.

Funding is being pumped into secondary care, such as hospitals, the proverbial ambulance at the bottom of the cliff.

But it’s well known that thousands of hospitalisations could be avoided with more funding for primary and community care.

The people most impacted by this flaw are older Kiwis, who Carolyn Cooper, the Aged Care Commissioner, argues haven’t been taken into account in health strategies.

People over 65 are the highest users of New Zealand’s healthcare system, and will be 20% of New Zealand’s population by 2028, so it’s becoming an urgent situation.

So urgent, in fact, that Kaihautū Tika Hauātanga (Disability Rights Commissioner) Prudence Walker has called access to primary health and aged care a human rights issue.

Walker holds the Human Rights Commission portfolios for health and older people.

“The GP shortages and shortages in aged care facilities raise critical human rights issues, including older people’s ability to live a life of dignity, the right to housing and access to healthcare, and to live in their own homes and communities if they want to,” Walker said.

She points to a paper published in the New Zealand Medical Journal, which found only 28% of general practices have enough resources to enrol new patients.

Rosa Kornfeld-Matte, the UN’s independent expert on the enjoyment of all human rights by older persons, in 2020 called for the New Zealand government to take action, to ensure the rights of older people.

Declining home ownership rates and rising living costs will increase material hardship, she warned.

The government needs to invest in affordable housing, she said.

Tough times in aged care

Aged residential care services have been crippled by years of underfunding.

Ansell Strategic last year found the sector’s earnings before interest, taxation, depreciation and amortisation (EBITDA) had fallen from $23.82 per occupied bed per day to $3.94 in just six years; a drop of 83%.

Researchers found that 56% of New Zealand’s 670 aged care centres were making a net loss of $4.24 per occupied bed per day in the 2023 financial year.

People tend to think of aged care providers as big, publicly listed companies who can subsidise hospital-level care with income from retirement villages or premium rooms – but these only make up 34.6% of the sector.

Small, individual owners or charity organisations make up the largest proportion at 43.4% of the sector.

This is particularly the case in regional New Zealand, as bigger providers tend to invest in cities.

Southland and Nelson reported the greatest losses, with an average operating EBITDA loss of $10 per occupied bed per day, Ansell Strategic says.

Where has the money gone?

Funding structures haven’t changed in 20 years. They’re currently under review, with recommendations expected in mid-2024.

The government has set a subsidised rate per bed per day, and much like general practices, aged care facilities aren’t allowed to charge anything more, based on the assumption that they can charge for premium amenities.

But many Kiwis are coming into aged care sicker and frailer than before.

In the over-65 demographic, 59% are disabled, according to a report from Cooper on seniors’ access to health and disability services.

The number of Kiwis living with dementia has jumped by 7000 people between 2016 and 2020, reaching 70,000. That’s expected to become 100,000 people in the next decade, and 170,000 by 2050.

Data from the New Zealand Aged Care Association shows the number of residents needing hospital-level care has grown 10% in the past five years.

But with critical staff shortages, providers are forced to close beds when they don’t have enough nurses to manage them.

In November, Aged Care Association chairperson Simon O’Dowd wrote in a minister’s briefing that 1000 beds had been closed in the past year, and 1200 closed temporarily, as a direct result of staff shortages.

Te Whatu Ora expects New Zealand will need 80,000 beds by 2040 - that’s double the number currently available.

But with the cost of adding a new bed about $250,000, few providers have capital to invest in growth.

Their biggest cost pressure comes from wages, with aged care providers often forgoing other costs such as maintenance work, trying to keep and attract nurses. The sector has about 760 nursing vacancies.

And it’s not just nurses’ wages that need lifting.

Caregivers who spoke to Stuff last year said they are often working on a ratio of two staff members to 27 residents, or four to 26 hospital-level care seniors.

With about 89% of patients in aged residential care facilities having some level of dementia, amid a critical lack of dementia beds, it isn’t unusual for them to be physically and verbally abused during their shifts.

The New Zealand Nurses Organisation has joined forces with the PSA and E tū unions representing care and support workers to file a Pay Equity claim in November.

The claim also covers home care support workers who help Kiwis stay in their own homes.

New Zealand Nurses Organisation’s aged care industrial adviser Louisa Jones says registered nurses are earning up to 12.79% less than their Te Whatu Ora counterparts, and healthcare assistants up to 23% less.

The alternatives

New Zealand introduced an Ageing in Place policy directive in 2002 with the goal of helping seniors continue living in their own homes for as long as possible.

But for this to work, they need access to home care support and primary care.

Cooper says it’s becoming increasingly challenging to consistently provide care to a proper standard.

Shortstaffing and complex funding arrangements mean some seniors with disabilities end up losing services when they turn 65.

Between 2015 and 2019, 20 home care providers left the market, mainly in urban centres. There’s likely been more closures since, Cooper says.

Many seniors wind up in aged residential care after being in hospital, but there’s a better chance of discharging them back to their own homes if there’s community support available to help them.

When there’s no spare aged care beds and no support in the community, they wind up stuck in hospital, which means the hospital has to defer planned care.

“A lot of people deteriorate at home because they don’t know how to access services. We want them to have quality of life,” Cooper says.

People over the age of 85 have a 25.5% drop in hospital admissions when they see a practice nurse regularly, Cooper says.

The problem with primary care

Minister of Health Dr Shane Reti recently called the sector “fundamentally broken”, referring to the existing GP funding model as a “blunt tool”.

Doctors want a funding model that recognises the complexity, co-morbidities and deprivation levels.

They too are short-staffed, and struggling to fund pay parity for their nurses.

A paper published in the New Zealand Medical Journal in March found only 28% of practices can take on new patients, while 27% have closed their books completely.

Adjunct professor Mona Jeffreys from Victoria University says the research team was surprised by how many practices had closed books.

And while closed books don’t affect existing patients, it does mean doctors don’t have time to help people with multiple conditions.

“You can see how burnt out these practices are. I don’t see a single GP sitting there happy because they had to turn patients away.”

There is strong evidence that early intervention prevents hospital admissions, and considering a night in hospital costs about $1700, compared to $372 for hospital-level aged residential care, Jeffreys says government money would be better spent investing in primary care.

The current general practice funding model is based on the idea that the average Kiwi needs only three 15-minute consultations a year.

Nelson GP Dr Graham Loveridge worries that some older patients aren’t getting the care they should.

“GPs are trying to do in 15 minutes what a doctor in a outpatient clinic would do in an hour,” he says, adding that it’s common for older people to have overlapping health concerns.

GPs are getting creative in the way they use staff such as nurse prescribers, he says, but those staff members still need oversight, and practices aren’t funded for that.

The new medical school

The Ministry of Health and University of Waikato signed a memorandum of understanding for a third medical school in February, with plans for a four-year graduate entry, rather than six.

But this is a long-term solution, and GPs say they need more urgent action.

The profession needs to be attractive for those graduating now, just to keep GPs in primary care.

General Practice Owners Association chief executive Mark Liddle says he’s encouraged by the record numbers of training places in general practice, but says replacing like for like won’t be enough.

“We’ve got demand outstripping supply.”

It’s a pressure that’s been building for the past 15 to 20 years, he says.

New Zealand Medical Students’ Association workforce spokesperson Andrew Xiao says while he finds the work rewarding, he also sees a sector that’s overwhelmed and unable to provide the necessary training.

“In order for us to grow our own workforce, it’s important that we invest in our primary sector,” Xiao says. “We need a healthy workforce for us to learn from.”

The pressure on GPs means limited placement opportunities.

Xiao says primary care is “an incredibly attractive career”, offering great relationships with patients, but it’s easy to be put off by the several hours of overtime GPs put in to make sure their patients don’t fall through the cracks.

“Ultimately, these are their patients, and they want to do the best for them, but our GPs are working around the clock to meet demands. It’s not sustainable.”

So how do we fix the situation?

Te Whatu Ora national commissioning director Abbe Anderson told the health select committee in March that closing the gap for the general practice workforce will cost about $170 million.

If the aged care and support workforce is included, the price tag rises to $1 billion.

Royal New Zealand College of General Practitioners’ Dr Samantha Murton says a full cohort of nurses will give practices the capacity they need to help train more staff.

There’s lots of evidence that offering care in the community is cost effective, Murton says.

“Whatever we do, the numbers stack up every time. The health system is the wrong way around.”

Cooper is calling for a health strategy for older people.

“Unless it’s on a strategy and at the top of the agenda, the Government won’t find it important,” she says.

“Primary care can, and wants to, do more.”

Minister for Seniors Casey Costell, who is also an Associate Health Minister, says she sees no need for a strategy for health and disability services for older people.

“The problems the commissioner [Cooper] is talking about have been around for some time and are not simple to address, but there is a unique opportunity for me as both Minister for Seniors and Associate Minister for Health to bring focus to this area, and to make sure that services for older people are connected and accessible.”

A solution will need to take into account a full spectrum of services allowing seniors to live as well and as independently as possible, she says.

That will include reviewing housing options and making it easier to build subsidiary homes, and finalising the aged care funding and service model review, which Costello is now responsible for.

“You are right that we need to think long-term about our ageing population, but I am hoping we can make some decisions around the funding formula this year as there are immediate pressures on some facilities. While we need to think ahead, I don’t want to see us losing existing beds in the meantime.”

Costello says there are already strategies covering seniors’ wellbeing: Better Later Life, the Healthy Ageing Strategy 2016, The New Zealand Disability Strategy, and the Carers Strategy.

Reti says as a former GP he’s “frequently reminded” of the sector’s pressures.

He acknowledges a position paper put forward by General Practice New Zealand in January, outlining solutions such as investing in workforce development, investing in planned care outside of hospitals, making seasonal adjustments to funding for rural practices, and facilitating data and information sharing.

“There are certainly some big discussions for me to have with Cabinet and with officials around how we tackle all this.”