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From onion sandwiches to filet mignon: the changing of the guard in residential aged care!

By Jim Toohey - posted Friday, 13 February 2009


We’ll call her Mary.

She was in her 90s - but still sound of mind and keen of wit.

She grew up in the bush - at a time when the bush really meant the bush; remote and isolated.

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She was orphaned in her early teens and as there was no one to take the children in, the family was broken up. She went to work as a servant girl for a wealthy family living on Moreton Bay; it was here she developed her lifelong love of seafood!

Eventually she married and had her own large family (nine children) and a husband, a World War I veteran, who had been wounded in France and returned to work on the railways.

One of her most vivid memories was trying to raise her children during the Great Depression on a railway worker's salary. Quite often, there just simply wasn't enough money to last between pays and the household would run very low on food. At such times, she used to employ a strategy of going without meals herself for several days, telling the family that she was sitting up late to do some mending and would have her dinner then. When they had gone to bed, she used to cut up onions and put them between the crusts of the left over bread.

When she told this story, she laughed at the memory of how long someone could last on black tea and onion sandwiches!

Mary lived in an aged care facility where she enjoyed the attention of a large and loving family. She shared a room with another three ladies who reveled in the company of each other’s visitors.

The building was old and institutional though clean and well maintained.

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The food was good but plain - her generation thrived on meat and three veg; that was all they asked for and to have it in abundance was considered a luxury.

Her life circumstances had conditioned her expectations. She was stoic and adaptive, she didn't make many demands and she rejoiced in a warm bed and the company of good friends.

Not long after she died, I met a member of her family who was packing up her belongings and preparing for her funeral.

He told me her house (which had been vacant for the three years she had lived in the facility) was going to auction in a couple of weeks time as the family had not been able to bear letting it go while she was alive.

The irony struck me - a well maintained house in a good suburb of Brisbane worth hundreds of thousands of dollars standing vacant while the owner had to share a bedroom with three others for the rest of her life.

While this didn't particularly concern Mary given the challenges she had faced, the contrast with the generations that followed her could not be more stark.

The number of Australians aged 65 plus is growing rapidly in its own right and as a proportion of the total population. The extent of this growth is unparalleled in our history:

  • in Australia the proportion of the population aged 65 years and over is estimated to double from 11.2 per cent of the population to 22.5 per cent by the year 2051;
  • there will be a decline in the 15-64 years age group from 66.6 per cent of the total population to 60.2 per cent by 2041;
  • there will be an increase in those aged 65 years and over from 8.7 per cent of the total population to 22 per cent by 2041. Within this group, the fastest growth is anticipated to be for those aged 80 years and over, with numbers increasing more than four-fold between 1993 and 2041. This group's share of the total population is expected to increase from 2.4 per cent to 6.9 per cent in 2041;
  • it is well-known that Australia is a nation of homeowners. For those aged 65 years and over outright home ownership is the highest for all age groups (81.9 per cent), followed by those aged 55 to 64 years (72.2 per cent). There is only a small proportion of aged persons in the rental sector; and
  • housing wealth (as measured by equity in the family home) is highest for those aged 55-64 years at $392,000 and slightly lower for those aged 65 years and over at $355, 000

However, all of these stats and their significance are dwarfed by the challenge of managing the completely different set of expectations and demands that Mary's daughters and granddaughters will have when they start to enter aged care in only a few years time.

Shared accommodation, modest physical environment, bus trips, bingo games and sing alongs just won’t cut the mustard any more. Mary's daughters and granddaughters will lodge a complaint if the pattern on the throw cushions doesn't match the curtains.

That's where the real challenge lies - in resourcing, on an economically viable and socially just basis, the specialised accommodation, services and care for record number of frail aged recipients who require it.

The answer of course is as obvious as the nose on your face.

As do its contemporaries in the OECD, Australia has to ask residents who are able to do so to pay more of the costs associated with their long-term accommodation and services rather than having the major burden fall on the taxpayer while hundreds of thousands of dollars of the residents own assets are left for the benefit of others.

It’s not a concept which is inconsistent with policy and practice in Australia - generally everyone uses the proceeds from the sale of their old home to finance their new one. Low care (hostel) facilities have been charging accommodation bonds (Government guaranteed and refundable on departure less legislated draw downs) for years; even for residents with dementia.

It is not contrary to the concept of a caring society; the health system was never meant to fund long-term accommodation and services - just quality health care.

It is economically sensible; it's not realistic to continue to increase taxpayer outlays for services which could easily be afforded by the recipients who have hundreds of thousands of dollars, in many cases, of assets sitting idle.

It comes down to the political considerations as always.

The coalition government tried to introduce this reform in 1997 and it was howled down; ironically by many who today are it’s greatest champions. The current government knows that this is an option that has to be on the table but is understandably wary of the political minefield it entails.

However, it should reassess (independent of the ideologues who drive the program) the growing level of support in the community for the concept.

If no substantial change occurs two things will happen:

  1. the number of aged care providers becoming insolvent (which was at record levels even before the global financial crisis) will continue to rise placing a greater burden on the public health system. It’s unknown if the impact of a very large provider (1000+ beds ) falling over has even been genuinely risk assessed by the health bureaucrats; and
  2. new, purpose-built single room modern facilities costing approximately $200,000 per bed to construct, simply won't be built. More, older facilities will operate longer and future generations of aged care recipients won't be able to find a place or at least not one which meets their expectations.

It reminds one of the scene from The Untouchables where Sean Connery tells Kevin Costner that everyone knows where the booze is. The problem is who's got the guts to kick the door down and do something about it.

Incidentally, I went to Mary's funeral, as did many members of the facility (residents and staff) in which she lived.

It was a great occasion - lots of tears but also many smiles and the celebration of a wonderful life.

The funeral was expensively catered - not an onion sandwich in sight.

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About the Author

Jim Toohey is a practicing Catholic and former Catholic seminarian.

Other articles by this Author

All articles by Jim Toohey

Creative Commons LicenseThis work is licensed under a Creative Commons License.

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