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The residential care system has undergone major changes over the past 15 years. It is a system that has traditionally been divided into two tiers: high-level care (nursing home care) and low-level care (hostel care). This situation has been somewhat muddled by legislative changes enacted in October 1997 allowing residential care facilities to house residents of any degree of dependency, and in fact 18% of residents in hostels are classified as requiring "high-level" care (Commonwealth Department of Health and Aged Care, WA Branch, personal communication), a situation that should mean that nursing attention is available 24 hours a day.³ However, statistics analysed and reported by the Federal Government over the period 1985-1997 demonstrate a consistent trend towards fewer nursing home beds and slightly more hostel beds,³ a trend which has probably continued over the past three years.

Despite a rapidly ageing population, there has been virtually no growth in the number of nursing home places. In Australia there were 71 503 nursing home beds in 1985 and 74 233 in 1997 -- a reduction in the ratio of beds per 1000 persons aged 70 years and over from 66.5 to 47.6. Over the same period, there has been real growth in the number of hostel places from 34 885 to 64 825 places, or an increase in the ratio from 32.5 to 41.6 beds per 1000 persons aged 70 years and over.

These changes have produced predictable results, with a notable and sustained increase in levels of dependency of residents in nursing homes and hostels. In 1987, 30% of permanent nursing home residents were categorised as "high dependency" (Residential Classification Scale Index 1 or 2); in 1997, this proportion was 56%. In 1992, only 54% of hostel residents required assistance with personal care, whereas in 1997, 80% of residents required such assistance.³

Older people in residential care are the sickest and frailest subsection of an age group that manifests the highest rates of disability in the Australian population. For example, in 1998, only 5.2% of people aged 65-69 years required assistance with self-care activities (eg, bathing, dressing, grooming), while in the age group 80 years and over 31.4% of people required such assistance.³ As people age, they are not only more likely to have a severe or profound disability but are also more likely to be cared for in residential care. Approximately 15% of Australians aged over 65 years living in the community have a severe or profound disability, whereas 93% of people in residential care have such a disability. While one-third of older Australians aged 65 years and over with severe or profound disability live in non-private dwellings, the rates rise from only 13% of the 65-69-year-old group to over 50% of women over the age of 80 years. This increase is almost certainly due to two main factors: the decreased availability of informal carers for the oldest age group, and the increasing level of disability.

What are the medical conditions underlying these dependency statistics? Unfortunately, although the Federal Government is responsible for both medical and residential care, few data are available on the common medical conditions of elderly people in residential care. Probably the commonest condition seen in these people is some form of dementia. In 1996, there were an estimated 134 809 people with dementia in Australia (this estimate does not include all people with mild disease).⁴ Approximately half of these individuals were housed in residential care.³ Estimates of the prevalence of dementia in people in hostels and nursing homes were 28% and 60%, respectively, although rates of cognitive impairment were even more alarming, at 54% and 90%, respectively.⁵ The main disabling conditions of the 707 600 people aged 65 years and over with a profound, severe or moderate disability (less than 20% of whom were housed in residential care) were arthritis, other musculoskeletal conditions, dementia, eye disease and stroke.³ It would appear that much of the disability suffered by people in residential care is related to chronic degenerative conditions.

The pressure of caring for people with increasingly complex and disabling conditions within the residential care system may place other parts of the healthcare system under stress -- for example, the readmission of nursing home patients to the acute hospital system with acute complications of chronic medical problems. Such admissions (eg, the referral to an acute hospital of a nursing home resident with severe Alzheimer's disease complicated by hypostatic pneumonia) may be precipitated by avoidance of ethically difficult management decisions. Another part of the health and welfare system that may come under pressure is community care, despite substantial real increases in Commonwealth expenditure on Home and Community Care (HACC). This expenditure has increased, in inflation-adjusted terms, from $561 million in the financial year 1991-92 to $799 million in 1997-98.³ The pressure exerted by reduced availability of residential care has led to a waiting time of several weeks for community care in many parts of Australia, despite the necessity of providing care to patients discharged from a crowded acute hospital system.

How should the provision of healthcare for people in nursing homes and hostels be organised? This issue has essentially not been addressed to date, and improvement in this area will require more than increased funding. Over the past 15 years, the focus of aged care services has been to prevent or delay the need for residential care by comprehensively assessing patients to identify those who might benefit from multidisciplinary rehabilitation and community services. The rationale for this approach is sound and clearly evidence based,⁶ and the policy has been very successful. While cynics may claim that the Federal Government has promoted the policy to halt the previous exponential growth in nursing home care, there is no doubt that older people themselves eschew the residential care option to remain in their own homes, if at all possible.⁷ However, the healthcare of people who go into residential care seems to be far less coordinated. Recent developments (part of the Enhanced Primary Health Care Initiative) that support medical practitioners in screening the over-75-years group and in care planning, exclude people in nursing homes. Furthermore, the organisation and proposed evaluation of this initiative do not appear ideal.⁸ The very high prevalence of cognitive impairment among people in residential care limits the usefulness of surveying residents about their perceived needs and decreases their ability to be effective advocates for their own care.

I believe several steps need to be taken to improve healthcare for people in residential facilities:

• We need to recognise that most older people do not choose residential care for "social" reasons. They do so because of chronic medical conditions resulting in permanent disability.

• Healthcare professionals need professional development involving training, peer review and transparency of operations, something that is apparent from the experience of acute care hospitals. (While accreditation of facilities may be a useful and long overdue stage in the development of residential care facilities, it is unlikely to improve the quality of healthcare provided.)

• Educational institutions, expert groups and professional organisations need to form strategic partnerships to establish what is currently accepted best practice in residential care and where investment should be made in targeted research.

• Health professionals working in the residential care environment should be trained in dealing with people who have major disabilities. This particularly applies to general practitioners, who should be encouraged to acquire specific qualifications and rewarded by increased remuneration.

• We need to develop a multidisciplinary team approach to healthcare delivery in residential facilities.

• Appropriate agencies, such as governments and private health insurers, need to provide sufficient funding to support the level of professional care required.

Medical practitioners and some other health professionals may be able to get expert support from regional aged care teams; however, these services are currently under considerable stress because their funding has not kept pace with the increasing number of older people requiring care.³ A wider role for geriatricians and psychogeriatricians in supporting these developments is crucial.⁹

There is no need for the widespread nihilism that has pervaded the issue of healthcare in residential facilities -- indeed, it has been shown that legislative changes¹⁰ and educational initiatives¹¹ can decrease the rate of inappropriate psychotropic drug use in nursing home residents.

Healthcare for people in residential care is provided not only by medical practitioners, but also by other professionals. The largest group of professional carers are nurses, for whom professional and best practice guidelines are similarly underdeveloped. For example, there are no guidelines specifying which of the available care strategies for people with dementia (such as validation therapy,¹² reality orientation¹³ or reminiscence therapy¹⁴) works best, and for whom. Similarly, other healthcare workers, such as dentists, pharmacists and allied health practitioners, all need to pay special attention to this vulnerable section of the population. A recent survey of Adelaide dentists¹⁵ revealed that their interest in and provision of services to people in residential care were low and that dentists provided little educational assistance for staff of nursing homes. A concurrent survey of the needs of the residents found a high level of standard dental treatment needs, with the severely cognitively impaired residents having the highest incidence of oral disease.¹⁵ Clearly, a diverse range of best practice guidelines for the care of residents of nursing homes and hostels is needed, together with appropriate resources to implement them.

It is sometimes argued that these residents have "reached the end of the road" and that further attention to their needs is unjustified. This argument is usually rejected by the very many Australians whose relatives and friends are housed in residential care. Perhaps more telling is the realisation that entry into residential care is a common occurrence in our society, and in fact any individual who lives to the age of 65 years has a 33% chance of requiring a nursing home bed during their remaining life and a 20% chance of requiring a hostel bed.³ It is in the interests of all members of society to provide more adequate healthcare in this challenging environment.

Disclosure statement: No conflict of interest.

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