John Deicke & Ingrid Marshall on Aged Care

21 October 2021

For the first edition of our quarterly e-newsletter The Brief, Marketing & Communications Manager Emma Eldridge sat down with Director John Deicke and Associate Director Ingrid Marshall to talk aged care.

Emma: How did you start working in aged care? What changes have you observed since then?

John: Before Deicke Richards, I worked in health care – for Conrad Gargett here and Llewelyn Davies in London and Hong Kong – designing major hospitals. In those days, there was a strong link between health and aged care. When we started Deicke Richards, our work was predominantly in social housing, so that health experience didn’t seem relevant, I suppose because of scale. But as the practice developed, we took a different approach to the idea of housing – one that encompassed designing homes for older people and those living with disability. So we took a strategic position to pursue that sort of work. Aged care was shifting at that time, from a health to residential model – places that felt like home and not facilities. Providers were looking for practices without a strong history in aged care. That gave us an opportunity.

Ingrid: I fell into it once I was in the office. But my background before practising architecture was in speech therapy and audiology, so I was able to bring those skills to the work.

John: We also collaborated with the University of Sunshine Coast on a research project around housing preferences for older Australians. We found that ageing in neighbourhood – providing a range of options within the community – was a viable solution, with location just as important to elders as dwelling. Attachment to community increases as we age, and connection enhances health and wellbeing. So we explored infill development and how to diversify retirement living and aged care, and that influenced our conversations with clients and local authorities.

Emma: Can you share your thoughts on the recommendations of the recent Royal Commission into Aged Care Quality and Safety? How do you see Deicke Richards using design to shift standards – and culture – as a result of the Royal Commission?

John: There’s three things, in my opinion, that will influence aged care and where it goes. One is policy – and that framework has started changing. The government’s push for home care packages, that was a big change – placing packages with the client and not the provider. That choice will ultimately enable elders to stay at home. That’s a policy driver but also an economic one as it’s cheaper to have someone live in their home than in aged care.

Sometimes with aged care it’s going back to what you used to do. There was a time when aged care residences were broken up into small houses. We’re going back to that model as it worked really well. The problem is how to fund it; we still haven’t resolved how to do that properly, the staffing costs are prohibitive.

And then there is the physical environment. More people staying at home with home care packages means they enter aged care much later. Low care becomes high care. So that changes the way people think about aged care.

Ingrid: I feel with the physical environment, some still haven’t caught up with that change. The new providers are responding to that, but there are still a lot of residences that were built to provide a more low care model, where there’s greater distances for people to travel, they don’t require support in the bathroom and things like that – they are still in existence and not ideal. In those environments, it takes more time for staff to do their jobs, which means more money, so it perpetuates the problem.

With my involvement with the group Places for Ageing, I keep saying, ‘Unfortunately, in the end a lot of it comes back to money.’ I remember talking to one of our clients, we were visiting a residence that someone had suggested we go and look at as a good model. And we came out and sat down for a coffee, and he said to me, ‘Is this all we’ve got to look forward to?’ The staff were lovely, they were doing everything they possibly could. The physical environment, it was all clean and tidy and nice. But it just wasn’t a place you wanted to be – it didn’t feel like home. And that’s what we try to achieve in our work, to create places that feel like home.

You know, I was a bit disappointed with the Royal Commission, with the recommendations. It did a tremendously good job of awareness raising, but it didn’t issue mandates in relation to staffing. We have those regulations for child care, why not aged care?

John: The two things things the government wouldn’t do was go user-paid – so if you can afford to pay, you pay – and introduce a Medicare levy to fund aged care.

Ingrid: Because the NDIS is having problems. I think that if they make the NDIS work, they will adopt the same strategy for aged care. But I don’t think anyone has understood how big a job looking after people with high needs, with disabilities, is. And it can’t be standardised.

John: We shouldn’t look at aged care funding purely in terms of direct financial cost. We have to look at it holistically – are there new models that may be cost neutral or more expensive but have broader financial benefits across the whole of society? So reduced hospital stays and medication needs and greater capacity for self care, which would deliver improved quality of life for elders. That to me is one of the financial challenges going forward.

Ingrid: Our clients are very cognisant of the Royal Commission and the impact it could have on their work. Their response has been to put things on hold until they can work out what will happen, because it’s such a big risk. We’re lucky to have clients that tend to look at what the options might be – they are interested in being ahead ahead of the ball and providing what people actually want, they want to make it work.

John: And that’s got to be the driver for aged care moving forward. What does the future hold? Will we continue building aged care residences as we always have or move toward other models, both in terms of care and funding that will chart a completely different future? We have heard a view expressed that aged care will be become much smaller and specialised. We know dementia and palliative care, for instance, work best in very small residences. And then, of course, with increases in home care funding, there are the people that will continue to live at home and ultimately die there, very content.

Ingrid: With regard to our role in making that shift, I remember a client saying to a counterpart we both work with that they like working with Deicke Richards because we don’t tell them how to do their job; we’re responsive, not didactic. One of the advantages in working with a range of providers is we are exposed to many different care models. So we bring that knowledge along, we share it and suggest alternative approaches, but we also listen.

Emma: Aged care design is becoming increasingly important as our population ages. What do you consider the opportunities inherent to this work?

Ingrid: I think there is a market for seniors-friendly housing. It doesn’t have to have all the bells and whistles and grab rails built in – but it does have to be able to have them. It could be units, strata titled, where those considerations have been made. My neighbour’s mother used to live in a place where there was six units, but only five residents. While they were all well enough, they could get family into stay and book that spare apartment. But as they got older, they got a nurse in. So the five people paid for a nurse to live there and care for them.

John: I think moving forward there’s going to be a plethora of different models – and that is complex. Some people might move into an 120-bed residence, others might prefer a small block of flats with friends. What remains is cost and changing expectations as to where people want to live and what kind of dwelling they want to live in. Our research supports the idea that you can actually have, within an established suburb, six or seven different hubs that are retirement living or aged care – that are separate but operate together, even if they’re hundreds of metres apart. So then it’s about how the providers service them. That will be the future and it’s probably closer than we think. We’re at the start.

Emma: Future cities will be older than anything we’ve experienced. What will it mean to maintain liveability when a quarter of the population is of retirement age, and how can the state and designers best share responsibility for this?

Ingrid: One of the things that an ageing population needs, even if their housing is suitable, is public transport. At some point people stop driving. Until there are self-driving cars, which there could be quite soon, that is something that has the potential to support older people living in the community.

John: It’s interesting, because transport is really important. Some providers are already operating buses that connect elders living in the community with their hubs. At some point in the next 10 years, we will have a cure for Alzheimer’s Disease, dementia. It’s getting closer and closer. Of course, one of the big drivers for aged care is dementia, so that will be a big change. Thinking of ageing holistically, which is not about care but keeping people healthy. There are studies looking at the impacts of getting elders into health centres and gyms and ensuring they are exercising, doing weight training– and the changes in quality of life can be significant.

So you can be pessimistic about it, having an ageing population, but what if that population is becoming healthier? How great would it be to have elders that are happy and healthy and able to look after themselves – until the very end, when they can access high quality care. And that will involve a real cultural change, how we view ageing. Our role as a society will be to keep elders out of care. Hopefully, one day we will do ourselves out of a job, which will be a wonderful thing.

Read about our retirement living and aged care work here.