Time to rethink the care of “our most vulnerable” by Chris Perkins

Covid-19 should make us re-think our care of frail older people. Despite amazing efforts ̶ coronavirus entered only six out of 650 facilities in Aotearoa New Zealand ̶ most of the people who died were in aged residential care. The deaths in older people’s accommodation throughout the world have been truly horrendous. What did we expect? This is a very vulnerable group, and we know that infections such as influenza and norovirus regularly sweep through and kill residents. Why do we still put our elders in institutions like this?

Institutional care is a way to look after large numbers of people (relatively) cheaply. First it was the poorhouses and workhouses that got people off the streets and out of sight but afforded only a wretched existence. Later asylums sheltered (or hid) those who were mentally ill or deemed antisocial. Intellectually disabled people were placed in large establishments such as Kimberly or Mangere, and their families told to forget about them. Criminals have always been shut away. Aged residential care began in the 1950s to support “indigent” older people who had no family to look after them. As family size shrank and more women went out to work, more places were built for those deemed unsafe to live independently.

In more enlightened times, we began to think that people have a right to pursue their own lives as they choose. We recognised the damage done by institutions; they fit the person to their routines rather than the other way round. They cannot allow much freedom of expression or resistance to the depersonalising effects of being one of many. Orphanages were shut and the children fostered to families. Mental hospitals closed and inmates discharged to community care. (The ex-patients overwhelmingly preferred life out of the long-term hospitals despite the failings of mental health services.) People with an intellectual disability went to live in small homes in groups of four or five in the suburbs; they became part of society. Currently, just prisoners and old people live in institutions.

With the population of older people increasing, only the very disabled, 70-80% of whom are cognitively infirm, can be admitted to rest homes and private hospitals. Their needs are extensive and expensive demanding large numbers of well-trained staff. However, the mandated minimum staff levels have not been reviewed since 2005 when there was a vastly different cohort of people in care. A shortage of skilled staff means that residents are often sedated so they can be “managed” within the system, rather than offered personalised solutions to their boredom, anxiety or discomfort. The recent interim report of the Australian Royal Commission into Aged Care is titled A shocking tale of neglect and calls residential care a “cruel and harmful system”. The deficiencies in community care are reported as “cruel and discriminatory.” Having worked in both Australia and New Zealand, I doubt if our system is any better

Older people rarely ask to go into care. In fact, one of the commonest pleas we hear is, “Don’t put me into a home.” Yet we have not tried very hard to imagine alternatives. Home care services and day programmes are often not flexible enough in what they offer, or when, to fit in with older people or their families. We might consider other options such as the provision of greater whānau support (paying family members to care, night-time sleep-over staff and so on), warden-patrolled flats, funded foster care, holidays for frail older people, free respite care (in home and out) that can be pre-booked and/or available in emergency or small group homes for people with dementia. Some of these services are probably not commercially viable and the DHB would have to provide them. Especially, we need a tolerance for risk and eccentricity among our old people who want to age and die in place. If Covid-19 teaches us anything, it is that our “most vulnerable” are not protected in their institutions.

Chris Perkins is an undergraduate student at Massey University. The above blog was entered into the 2020 Student Blog Writing Competition.