Summary of Aged Care Royal Commission Hearing – Workforce – 21 February 2020

At this Hearing, the Commissioners:

• heard evidence from two international expert witnesses; and
• received proposed recommendations from Counsel for inclusion in the Final Report concerning reforming the aged care workforce, primarily focussed on residential aged care.

Counsel noted that the home care workforce raises a number of unique challenges that will be addressed separately at a later stage.

Counsel believed that the evidence gathered over the workforce hearings highlighted that the aged care workforce is at risk of collapse. It was noted that these problems have been identified before and have only become further embedded as a consequence of inaction and growing care needs.

By way of context, Counsel also noted that the overwhelming weight of evidence received by the Royal Commission suggests that the care needs of people in residential aged care have increased significantly in recent years.

Counsel outlined that the workforce recommendations are based on the following principles:

• Approved providers should meet mandatory minimum staff requirements; registered nurses and nurse practitioners should make up a greater portion of the workforce.
• Aged care workers should receive better training; unregulated workers should be subject to registration with minimum mandatory entry requirements.
• The care workforce should be better remunerated and work in safer conditions.
• The organisations should be better managed and governed.
• The Australian Government should provide practical leadership.

Counsel acknowledged that the recommendations will require significant reform of the aged care sector, including in relation to regulation, governance and funding.

In particular, Counsel noted that, in conjunction with recommendations about system design, funding and financing, regulation, provider governance, the role of the Australian Government and other areas which Counsel will be proposing in the coming months, the implementation of the recommendations proposed at the workforce Hearing should result in improved quality and safety of aged care.

Counsel’s Recommendations

• Mandated staffing ratios: an approved provider of a residential aged care facility should be required by law to have a minimum ratio of care staff to residents at all times, based on the following:
  • sufficient to achieve a 4 star rating under the current Nursing Home Compare system used for publicly funded nursing homes in the US (noting that staff ratios are not mandated in the US and that a large proportion of US nursing homes rate less than 4 stars)
  • average case-mixed total care minutes of between 186 and 265 minutes per resident per day comprising nurses (RNs and ENs) and personal care workers, depending on the care needs of each service’s resident profile
  • a minimum of 30 minutes of RN care time per resident per day
  • in addition, at least 22 minutes of allied health care per resident per day
  • a Registered Nurse present on each shift.

Counsel acknowledged the staffing challenges this would pose in rural and remote region and advised that these would be addressed at a later date.

• Increased transparency: providers should provide quarterly staffing level reports covering registered and enrolled nurses, allied health and other care staff by shift in residential aged care, and clear explanatory material to the Department of Health to be published and made publicly available. There does not appear to be a proposal requiring the financial acquittal of care-related expenditures.
• Geriatric care training:

Medical Deans of Australia, in conjunction with the Australian Medical Association, Australian Medical Council and the RACGP, should collaborate to:

• review the skills needed by GPs to enable them to meet the anticipated aged care needs
• determine the anticipated need on GP’s to deliver geriatric medical services, particularly in an aged care context, over the next 30 years; and
• review geriatric undergraduate medical education with a view to mandating core subjects.

Each Medical School to review its undergraduate medical curriculum with a view to making:

• geriatric medicine a core element of the curriculum; and
• placement in a geriatric clinical setting a required portion of internship training in advance of registration.
• Nursing training: the Nursing and Midwifery Board and the Nursing and Midwifery Council should incorporate an introductory module on geriatric medicine and gerontology care in the enrolled nurse and registered nurse accreditation standards.
• Supply of Nurse Practitioners: the supply of nurse practitioners should be increased via the use of ‘return of service’ scholarship programs.
• Mandatory minimum qualifications: Certificate III in Individual Support Ageing should be the minimum mandatory qualification for personal care workers performing paid work in aged care.
• Establish a registration scheme for personal care workers: key features include: mandatory minimum qualifications; obtained from certain approved training providers; ongoing training and professional development; minimum levels of English language proficiency; criminal history screening; and an investigatory body for breaches of the Code of Conduct.
• Leadership of the aged care workforce

Commonwealth:

• the Australian Government should lead workforce planning for the aged care sector and identify an agency or body that has overall responsibility for aged care workforce planning, with key responsibilities being:
  • long-term workforce modelling;
  • overall management of the training pipeline;
  • driving improvements in labour productivity across the health professions;
  • ensuring appropriate distribution of the health and aged care workforce, particularly across rural and regional Australia; and
  • facilitating the migration of health professionals and aged care workers.

• the Australian Government should work in partnership with the Aged Care Industry Council, and provide the financial and practical support necessary to implement the Aged Care Workforce Strategy Taskforce Report recommendations

Industry:

• Counsel noted that good leadership from providers is also necessary for workforce improvement and reform, and that recommendations will be made at a later time in relation to provider governance and leadership.

Witnesses

Professor Charlene Harrington (US) – Professor Emeritus of Sociology and Nursing, University of California, San Francisco

Prof Harrington provided an overview of aged care in the United States and explained that the US Centres for Medicare and Medicaid Service (CMS) website (Nursing Home Compare) is the ‘gold standard‘ for aged care information and rating nursing homes. She outlined a study that demonstrated that inadequate staffing levels, particularly of registered nurses, was directly connected to harm suffered by residents. The study demonstrated an individual resident required 4.1 hours contact with staff per day, including 45 minutes with a registered nurse.

Prof Harrington noted numerous challenges in monitoring and ensuring the provision of adequate staffing standards.

Dr Katherine Ravenswood (NZ) – Associate Professor in Employment Relations, Auckland University of Technology

Dr Ravenswood gave evidence regarding employment and workplace conditions in New Zealand, and outlined that the standard of aged care relates to the level of government funding provided. She outlined that standards of care are negatively impacted by low wages and gender-related discrimination in the workforce.

She also highlighted the 2017 Kristine Bartlett equal pay case in NZ that involved a claim that was settled out of court as a consequence of government intervention. Settlement prescribed four mandatory categories of wages for carers based upon the level of individual qualification, which was subsequently legislated.

Dr Ravenswood noted that while the settlement successfully implemented mandatory minimum standards, delivery of the scheme has seen providers employ staff with lower categories of qualification and shorter shift lengths to reduce costs. She explained the scheme has created a perception that workers are now paid more and therefore should take on a higher workload.

Dr Ravenswood advocated for attaching labour standards to the minimum criteria for accreditation for providers with a view towards providing adequate staff numbers and fair remuneration. Additionally, she advocated for changing social values through social campaigns to improve the public perception of aged care workers.

A Selection of Quotable Quotes by Counsel

• “The staff in our aged care homes are not well paid. There are all too often not enough of them to provide the care they would like to give. Many work in stressful and sometimes unsafe workplaces. Some are untrained, others have inadequate training.”

• “Addressing the significant challenges will require new thinking; it will require policy makers and the sector to take some risks. Not every measure will succeed. This must be accepted.”

• “…the time for real action on staffing numbers and mix, remuneration, conditions of work and registration of the unregulated portion of the aged care workforce is now.”

• “ We consider there are, and will continue to be, significant differences between workforce policy in a residential aged care context, which will increasingly be dementia-related and end of life focussed, and aged care in a home care context. The two settings are very different and call for very different and tailored policy responses.”

• “Over the last 20-25 years, we have seen a shift away from people entering care with lower needs and for social reasons.”

• “The most efficacious way of ensuring high quality and safe care in a residential setting is by imposing requirements on the providers of that care to have a minimum number of care staff in a mix that takes into account the care needs of their residents.”

• “It goes without saying that the proposal for mandatory minimum staffing levels cannot be achieved within the current funding envelope.”

• “Evaluation and recalibration of the mandatory minimum staffing levels is something that should be incorporated.”

• “….evidence demonstrates that requiring minimum staffing numbers is a necessary but not sufficient step towards improving quality and safety. The other steps include improved training, better management and more attractive terms and conditions of employment.”

• “If there is one constant theme running through all of the Hearings, it is the concern raised about the lack of appropriately trained staff in residential aged care and the impact of staff shortages on the quality of care.”

• The proposed case-mix based ratio “is flexible in that it permits several different combinations of nursing and care staff to reach the same star rating level …. allowing for homes to have a quite different mix of staff in each home, depending on the unique needs of their residents.”

• “There does not need to be a trade-off between a social model of care and a clinically competent model. Residents have a right to both.”

• “We submit to the Royal Commissioners that any re-design of the aged care system that does not remove the incentive that presently exists for providers to reduce the number of nurses that they employ to cut their costs will necessarily fail.”

• “…the establishment of the Human Services Skills Organisation pilot creates the potential for inconsistencies and duplication of effort given the Aged Services IRC will continue to operate and have carriage of important pieces of work. The RC will closely monitor the work that is occurring around reforms to skills and training that will impact on the aged care sector.”

• “The RC staff will consider the best way to encourage ongoing training and professional development of staff, and note that many providers have shown leadership in this regard.”

• “Evidence the RC received indicates that undergraduate and diploma level nurse education and training is not adequately preparing nurses to care for older people….with skill and knowledge gaps in wound care, managing continence, nutrition, dementia and gerontology.”

• “…there is a strong case to support the nursing practitioner model, alongside the medical workforce, to improve access to quality primary care in residential aged care.

• “the existing Commonwealth law is a very limited measure to ensure that those people who are unsuitable for aged care work are excluded from working in the sector.”

• “The costs of implementing a registration scheme (for personal care workers) needs to be considered and, of course, the question of who bears those costs. The Royal Commissioners are aware of the need to minimise the financial burden to the workforce and to avoid a registration scheme having negative consequences in terms of workforce supply.”

• “….evidence suggests that merely increasing the level of subsidies paid to providers is unlikely to translate into higher levels of remuneration for the workforce.”

• “….neither the low wage bargaining stream nor equal remuneration order are likely to be fruitful….history suggests that without strong Federal Government commitment and a cooperative approach that involves the employers, unions and care recipients, success will be illusive.”

• “The Royal Commissioners are undertaking work examining the governance of aged care services, and recommendations will be made in relation to provider governance and leadership at a later time.”

• “There appears to us to be a lack of leadership and expertise about aged care within the Department of Health.”

• “The evidence paints a concerning picture of a government that does not see itself as a leader (in relation to workforce) but at best as a facilitator.”

• “There is a need to build the Commonwealth’s own workforce given the pivotal role it plays in the administration of My Aged Care, the various regulatory functions by the Department of Health and the Aged Care QUALITY AND Safety Commission.”

• “….it suggests an approach at the highest levels of the aged care bureaucracy that is timid, risk-averse and more worried about political risk than making a contribution to the vital issue of aged care reform.”

Catholic Health Australia