Conclusion and recommendations

5.1        The aged care sector in Australia is undergoing significant growth and change. Factors contributing to this include:

• the growth in the ageing population, and projections of a significant rise in the proportion of people aged 65 and over;
• increasing diversity in the ageing population;
• greater complexity of healthcare needs in those accessing aged care;
• significant changes to aged care service delivery and the impact of new technologies; and
• growth and change in other sectors, in particular, the disability care sector with the roll out of the National Disability Insurance Scheme (NDIS).

5.2        The government has placed considerable focus on establishing the NDIS and establishing a user determined model for disability service delivery, which it has also introduced into the aged care sector as the 'consumer directed care' (CDC) model. It is the view of this committee that, in doing so, there has not been sufficient focus on the unique challenges associated with aged care service delivery and with the changing aged care sector. This is particularly evident in relation to regional and remote services and service delivery to diverse communities.

5.3        The committee is concerned to ensure that service delivery changes, and other ongoing challenges facing the aged care sector, receive sufficient focus and support from government.

5.4        The committee has heard that the aged care workforce will need to grow by two per cent per year to accommodate demand for services, yet there is no clear plan in place as to how this will be achieved. The committee also heard that ageing Australians living in remote or very remote locations, and the service providers and workers delivering services to them, cannot rely on the CDC model of service delivery alone to provide an appropriate level of care.

5.5        The aged care workforce, which is the focus of this inquiry, is being significantly affected by ongoing issues with pay and conditions. Workers often struggle to secure competitive pay and conditions, relevant and timely training, and have fewer career and advancement opportunities than may be available in other comparable sectors. They also face, in the changing aged care sector, greater insecurity as the model of service delivery changes. For regional and remote workers, these challenges are felt more acutely, particularly in relation to training and professional development, and insecurity in the face of the introduction of CDC.

5.6        There are four key themes that arose during the inquiry:

• the need for an integrated sector-wide workforce development strategy;
• the need for improved training;
• the need for further workforce and workplace regulation; and
• the particular challenges facing the aged care workforce in remote communities.

Aged care workforce development strategy

5.7        Throughout this inquiry, there has been an almost universal call for a workforce strategy that should be developed by key stakeholders in the aged care sector, including service providers, representatives of workers, consumers, their carers, and government.

5.8        The committee welcomes the government's announcement to commit resources to support the establishment of an industry-led taskforce to develop a national aged care workforce strategy. The committee also notes the aim of the taskforce to explore short-, medium-, and long-term options to address supply, demand and productivity issues for the aged care workforce.

5.9        In establishing and setting the direction for the workforce strategy taskforce, the following issues have been identified during this inquiry that should be addressed:

• taskforce composition;
• interaction with the NDIS Integrated Market, Sector and Workforce Strategy;
• workforce issues including wages and conditions, career structures, development opportunities and succession planning;
• deficiencies in data;
• the role of informal carers and volunteers;
• the role of medical and allied health professionals;
• mandatory minimum nursing requirement; and
• the challenges of service delivery to a diverse, and geographically dispersed, population.

Taskforce composition

5.10      The committee considers that the aged care taskforce must be representative of all stakeholders in the aged care sector. The composition of the taskforce should include representation from across the full range of service providers (public (state, territory and local government), for-profit, not-for-profit, urban-based, remote and very remote), workforce representatives from across the spectrum of aged care sector employment categories, including nurses, care workers/personal care attendants, medical and allied health professionals, and others, and representatives of consumers and volunteers.

5.11      The committee notes that the government regulates, sets the policy direction for and is the main source of funding and revenue in the aged care sector. The committee considers that the government has a responsibility to ensure that the aged care sector responds to workforce challenges in a way that will make best use of the considerable public funding that supports and underpins the aged care sector. The government should be more than a mere 'facilitator' for an industry-led response to the aged care workforce challenges.

5.12      Given that the strategy must be developed within the broader context of aged, disability and health care delivery, the government must play a key role in the development of the workforce strategy to ensure the proper alignment of policy and outcomes across different sectors, where this will achieve better service delivery, value for public expenditure and address workforce shortage issues. These are not matters that the aged care industry can or should be required to achieve on its own, or even with government facilitation. This is something that requires active participation and leadership from government.

5.13      The committee believes it will be important to take an holistic approach to the National Aged Care Workforce Strategy, to ensure that all levels of government, consumers and related stakeholders are appropriately consulted in the development and implementation of the Strategy.

Recommendation 1

5.14      The committee recommends that the aged care workforce strategy taskforce be composed of representatives of service providers, workforce groups, including nurses, care workers/personal care attendants, medical and allied health professionals, and others, and representatives of consumers and volunteers. Representatives of workers, care providers and consumers from regional and remote areas should also be included.

Recommendation 2

5.15      The committee recommends that the government, as a key stakeholder in aged care in terms of regulation, policy, intersections with other sectors and the coordination of government involvement, and as the key source of funding and revenue for the aged care sector, must be an active participant of the taskforce and must take ownership of those aspects of the workforce strategy that will require government intervention and / or oversight.

Interaction with NDIS Integrated Market, Sector and Workforce Strategy

5.16      The committee has heard the concerns raised by the aged care sector that providers will progressively lose staff to disability service providers, and particularly so in regional and remote areas. The committee also notes that the government has recognised the similarities in the kinds of work undertaken, skills and knowledge required to provide aged care and disability services.

5.17      Evidence presented to the committee indicates that while many stakeholders welcome moves to better coordinate care across different sectors, for example, the disability sector, there are concerns that aged care policy, programs and funding may be at risk as a result of this move, which may see a shift of focus (and potentially resources) away from aged care service provision.

5.18      The committee further notes the 2017-18 Budget announcement of $33 million over three years to increase the supply of aged care and disability workers in rural, regional and outer suburban areas, with funding drawn from the Department of Health and Department of Social Services.

5.19      The committee considers that the aged care workforce strategy must be developed within the broader context of aged, disability and health care delivery. It should include review and consideration of existing programs and resources available, and refer to the NDIS Integrated Market, Sector and Workforce Strategy. The strategy must consider the opportunities that arise from overlapping workforce issues for the aged care and disability sectors, as well as the competitive pressures that are now beginning to emerge.

Recommendation 3

5.20      The committee recommends that the aged care workforce strategy include a review of existing programs and resources available for workforce development and support and ensure consideration of the NDIS Integrated Market, Sector and Workforce Strategy to identify overlapping issues and competitive pressures between the sectors and how they may be addressed.

Workforce issues

5.21      The committee notes the evidence of poor working conditions in the aged care sector, including comparatively lower pay than other similar sectors, lack of sector-wide career structures, difficulties for workers in accessing development opportunities and concerns over workplace health and safety issues. The committee considers these matters that affect many individuals in the aged care sector, and which can also impact on the quality of care delivered, require urgent attention and should be a primary focus of the workforce strategy.

5.22      The committee is concerned that pay and conditions for workers in the aged care sector are now becoming more uncompetitive with other sectors with the move to 'zero hour' contracts, which are intended to provide flexibility for aged care service providers, but which have the impact of further marginalising aged care sector workers and making the industry a less attractive alternative for workers.

5.23      The reputation of the aged care sector as a career choice for workers has been recognised by the industry as a significant barrier to attracting and maintaining staff. The committee considers that addressing the key workforce issues will go some way to rehabilitating the reputation of the industry; however, industry and other stakeholders also have a role in developing a more positive image of the industry.

5.24      The committee commends the work being undertaken by the sector to improve the image of the aged care sector, and considers the aged care workforce strategy as an important means of broadening these efforts across the whole sector.

Recommendation 4

5.25      The committee recommends that, as part of the aged care workforce strategy, the aged care workforce strategy taskforce be required to include:

• development of an agreed industry-wide career structures across the full range of aged care occupations;
• clear steps to address pay differentials between the aged care and other comparable sectors including the disability and acute health care sectors;
• mechanisms to rapidly address staff shortages and other factors impacting on the workloads and health and safety of aged care sector workers, with particular reference to the needs of regional and remote workers including provision of appropriate accommodation; and
• development of a coordinated outreach campaign to coincide with developments introduced through the workforce strategy to promote the benefits of working in the aged care sector.

Deficiencies in data

5.26      The committee acknowledges the work undertaken by the National Institute for Labour Studies (NILS) at Flinders University in ongoing surveys of aged care service providers and the aged care workforce, and considers it essential that this work should continue into the future. The committee notes, however, the limitations of the data available in relation to aged care and aged care service delivery. The lack of nationally agreed standards enabling the collection and analysis of the composition of the workforce across all relevant occupation groups needs to be addressed.

5.27      The committee considers it essential that the aged care taskforce review the workforce and other industry data available and ensure it meets the industry's needs for planning (and reporting) purposes. It is also necessary to ensure that data review and development enables comparisons between sectors, for example, the disability and acute health sectors.

Recommendation 5

5.28      The committee recommends that the aged care workforce strategy taskforce include as part of the workforce strategy a review of available workforce and related data and development of national data standards in a consultative process with aged care sector, and broader health sector and other relevant, stakeholders. Any nationally agreed data standards should enable comparison across and between related sectors where possible.

Informal carers and volunteers

5.29      The committee acknowledges the role of informal carers and volunteers in the provision of aged care services. The committee has heard that there is some concern that the CDC model introduced to aged care does not sufficiently account for, or enable planning in relation to, informal carers and volunteers.

5.30      The committee considers the convening of the taskforce to develop an aged care workforce strategy an excellent opportunity to consider the role of informal carers and volunteers and the issues and challenges for these very important groups within the context of the changing sector, and changes in the composition and size of these groups over time.

Recommendation 6

5.31      The committee recommends that the aged care workforce strategy include consideration of the role of informal carers and volunteers in the aged care sector, with particular focus on the impacts of both the introduction of consumer directed care and the projected ageing and reduction in these groups.

Medical and allied health professionals

5.32      The committee has heard evidence that allied health and medical professionals are underutilised in the aged care sector, particularly in rural and remote areas.

5.33      The committee agrees allied health and medical professionals need to be better integrated into the aged care sector. The committee considers that the proposed national aged care workforce strategy provides an opportunity to examine the current state of medical and allied health professional involvement in the aged care sector and opportunities to address care and skill shortages through better use of available medical and allied health resources.

Recommendation 7

5.34      The committee recommends that the national aged care workforce strategy includes consideration of the role of medical and allied health professionals in aged care and addresses care and skill shortages through better use of available medical and allied health resources.

Mandatory minimum nursing requirement

5.35      The committee is concerned that the ratio of workers to clients in some residential aged care facilities is too low, leading to the risk of compromising the quality of care delivered. It can also detract from the appeal of working in the aged care sector for many potential employees, and can lead to exit from the sector.

5.36      The committee notes the concerns expressed by residential care providers that mandating staff to patient ratios may not be the best solution to this challenge, and considers that mandating a minimum number of registered nurses working at any one time may be a more appropriate regulatory requirement. The committee also notes advice from the Department of Health that while a mandated staff to client ratio is not currently government policy, the government has been asked by the Australian Health Ministers' Advisory Council to consider, as part of the development of the single aged care quality framework, the inclusion of a standard that requires that clinical care provided in residential aged care be best practise and provided by a qualified clinician.

5.37      The committee also notes the findings of the Australian Law Reform Commission (ALRC) report on elder abuse commissioned by the Attorney General, which recommends that the government commission an independent evaluation of research on optimal staffing models and levels in aged care, and most importantly, make use of the evaluation findings to assess the adequacy of current arrangements.

5.38      The committee considers that such an evaluation must be undertaken in close consultation with all industry stakeholders, including aged care workers and service users and consider the costs and benefits of a range of options for better ensuring appropriate levels of clinical care in aged care facilities and services, how best to implement any agreed approach, and monitoring and evaluation of outcomes.

5.39      The committee also considers that a mandated requirement for residential aged care facilities to publish their staff to client ratios should be explored, given the shift to consumer directed care. Publication of such information is appropriate in order to assist consumers to make informed choices in their aged care planning.

5.40      The committee notes that any regulatory requirement imposed on aged care service providers may require additional funding and support from governments in order to meet the requirement.

Recommendation 8

5.41      The committee recommends that the government examine the introduction of a minimum nursing requirement for aged care facilities in recognition that an increasing majority of people entering residential aged care have complex and greater needs now than the proportions entering aged care in the past, and that this trend will continue.

Recommendation 9

5.42      The committee recommends that the aged care workforce strategy include consideration of and planning for a minimum nursing requirement for aged care services.

Recommendation 10

5.43      The committee recommends that the government consider, as part of the implementation of consumer directed care, requiring aged care service providers to publish and update their staff to client ratios in order to facilitate informed decision making by aged care consumers.

Challenges of service delivery to a diverse, and geographically dispersed, population

5.44      The committee considers that the aged care workforce strategy must take into account the context within which service delivery occurs, and the location- or culturally-specific skills, knowledge and experience that may be required of the workforce delivering those services. In particular, the strategy should recognise and address the particular challenges for attracting, retaining and training staff in remote communities, including issues in relation to housing, security, transport and remuneration.

5.45      The committee considers that a 'one size fits all' approach, as is being rolled out through the implementation of the CDC model in aged care, is problematic. This is particularly evident in the remote and very remote locations the committee has had the opportunity to visit and see first-hand as part of this inquiry. The committee has heard compelling evidence from service providers, aged care workers and other stakeholders of the need for a more tailored, flexible approach to aged care service delivery.

5.46      Aged care service providers delivering services to Aboriginal and Torres Strait Islander communities, particularly in more remote locations and often as the sole provider, are struggling to adapt to the CDC model, not through an unwillingness to try, but because this model is not appropriate to remote circumstances. In this context, a degree of uncertainty and concern over the ongoing viability of these services is adding to the existing challenges of attracting and retaining workers in remote locations. It is clear that more needs to be done to engage with and assist aged care workers and service providers operating in remote and very remote locations.

5.47      The committee notes that the government has supports and programs available to assist workers and service providers, but the evidence from this inquiry is clear: there are aged care service providers unable to access these services, or unaware of their existence. In some cases, the existing supports and programs intended to assist aged care providers do not meet their needs. The committee considers that these issues must be reviewed and addressed as a matter of priority.

Recommendation 11

5.48      The committee recommends that the government take immediate action to review opportunities for eligible service providers operating in remote and very remote locations to access block funding, whether through the National Aboriginal and Torres Strait Islander Flexible Aged Care Program or through other programs. The committee further recommends that consideration be given to amending the 52 day limitation on 'social leave' for aged care residents living in remote and very remote aged care facilities.

Recommendation 12

5.49      The committee recommends that the Department of Health review the implementation of consumer directed care to identify and address issues as they emerge. Specific attention should be paid to any impacts on remuneration, job security and working conditions of the aged care workforce, and impacts on service delivery in remote and very remote areas, and to service delivery targeting groups with special needs, as identified in the Section 11-3 of the Aged Care Act 1997.

5.50      The committee considers it essential to ensure that services delivered to Aboriginal and Torres Strait Islander peoples, people from culturally and linguistically diverse backgrounds, and lesbian, gay, bisexual, transgender and intersex peoples, are accessible, do not present barriers to access, and are culturally appropriate and appropriately resourced.

Recommendation 13

5.51      The committee recommends that the aged care workforce strategy ensure consideration of the service delivery context in which the workforce is expected to perform. The strategy should also include medium and long term planning for location- and culturally-specific skills, knowledge and experience required of the aged care workforce working with diverse, and dispersed, communities throughout Australia. This must specifically include addressing workforce issues specific to service delivery in remote and very remote locations.

Improved training

5.52      The committee is concerned by evidence there is considerable inconsistency in the quality, scope and suitability of aged care programs offered to students. Of particular concern is that some RTOs are offering courses that fall below the Australian Qualifications Framework (AQF) guidelines and standards. The committee notes that this means that some students are not attaining the necessary skills and practical training to commence work in the aged care sector.

5.53      The Committee notes the October 2015 Education and Employment References Committee inquiry into the vocational and education training (VET) sector, which made 16 key recommendations. Some recommendations were implemented by government, but not all. Key recommendations yet to be implemented include:

• Establishment of a scheme to ensure national consistency in disability worker training;
• Establishment of a disability worker registration scheme, including requirements for ongoing professional development;
• A national approach to State, Territory and Commonwealth service delivery accreditation programs; and
• ASQA maintain a close scrutiny of and give priority to the aged care training sector.

5.54      The same issues raised in the 2015 Education and Employment References Committee inquiry continued to be raised in this inquiry, specifically in relation to aged care training.

Recommendation 14

5.55      The committee recommends that all recommendations of the Senate Education and Employment References Committee inquiry into the operation, regulation and funding of private vocational education and training (VET) providers in Australia be implemented.

5.56      The committee notes the Australian Skills Quality Authority evidence that around 25 per cent of courses offered are still too short for people to get properly skilled and that no changes have been made to minimum course length requirements.

Recommendation 15

5.57      The committee recommends that the aged care workforce strategy taskforce work with Australian Skills Quality Authority to establish nationally consistent minimum standards for training and accreditation.

5.58      The committee notes the evidence that nursing courses do not have an aged care component as core curriculum, and there is a lack of dementia-skills training and that very few student nurses seek aged care facility placements during training.

Recommendation 16

5.59      The committee recommends that the aged care workforce strategy taskforce work with the Australian Nursing and Midwifery Accreditation Council (ANMAC) to establish aged care as a core part of the nursing curriculum, establish dementia skills training, and develop greater collaboration between the sector and nursing colleges to increase student placements in aged care facilities.

5.60      The committee is concerned at the particular challenges facing the aged care workforce in regional and remote areas in accessing appropriate training and professional development. It is clear that regional and remote aged care service providers often struggle to find appropriately trained workers, and that they also face difficulties in accessing affordable and suitable training opportunities for their staff, given the additional costs involved with travel, accommodation, temporary replacement staff, or in attracting trainers to more remote places to deliver training on-site.

Recommendation 17

5.61       The committee recommends that the government and the aged care workforce strategy taskforce develop a specific strategy and implementation plan to support regional and remote aged care workers and service providers to access and deliver aged care training, including addressing issues of:

• the quality of training;
• access to training;
• on-site delivery of training;
• upskilling service delivery organisations to deliver in-house training; and
• additional associated costs relating to regional and remotely located staff.

This strategy should take account of consultation and analysis such as that undertaken through the Greater Northern Australia Regional Training Network (GNARTN).

Recommendation 18

5.62      The committee recommends that the government work with the aged care industry to develop scholarships and other support mechanisms for health professionals, including nurses, doctors and allied health professionals, to undertake specific geriatric and dementia training. To succeed in attracting health professionals to regional and remote areas, scholarships or other mechanisms should make provision for flexible distance learning models, be available to aged care workers currently based in regional and remote areas, and include a requirement to practice in regional or remote locations on completion of the training.

Workforce and workplace regulation

5.63      The committee notes the concerns raised by aged care service providers and worker representatives that the absence of some form of registration of workers can have significant impacts, including on the cost and quality of care delivered in the aged care sector, and on the well-being of aged care workers.

5.64      The committee also notes the support for an examination of what might be the best approach in relation to workplace and workforce regulation, noting the concerns raised that any costs of regulation not unfairly burden aged care workers.

5.65      In examining aged care worker registration or other means of regulation, consideration must be given to ensuring that any restrictions on employment in the aged care sector are relevant and appropriate. In particular, the committee considers that historical criminal offences should be considered in employment decisions but should not automatically rule out a person's employment in the sector. The implementation of recommendations in the ALRC report on elder abuse in relation to the establishment of national employment screening for aged care workers and the establishment of a new serious incident response scheme, may help to ensure that appropriate and relevant factors are considered in the employment of aged care workers. The ALRC has also recommended that unregistered aged care workers be subject to the planned National Code of Conduct for Health Care Workers.

5.66      The committee notes the recommendations made during the committee's 2015 inquiry into violence and abuse against people with disability, regarding the regulation of the disability sector workforce and workplaces.

5.67      The committee further notes the work being done under the NDIS on care worker regulation. The committee believes that to enforce regulation and oversight in the disability sector but not in aged care, when there is growing workforce overlap, increases the risk to consumers in an unregulated aged care sector, where portions of the workforce might migrate to avoid scrutiny. The committee therefore considers that there is a need for aged care regulation to be at least consistent with that in the disability and acute health care sectors.

Recommendation 19

5.68      The committee recommends that the government examine the implementation of consistent workforce and workplace regulation across all carer service sectors, including:

• a national employment screening or worker registration scheme, and the full implementation of the National Code of Conduct for Health Care Workers;
• nationally consistent accreditation standards;
• continuing professional development requirement;
• excluded worker scheme; and
• workplace regulation of minimum duration for new worker training.

The regulation of the workforce must address:

• historical issues impacting on employment of Aboriginal and Torres Strait Islander peoples; and
• ways to ensure the costs of this regulation are not passed on to workers.

Concluding remarks

5.69      The committee has been continuously impressed by the dedication, passion and commitment of aged care workers and service providers operating in a very challenging and changing environment.

5.70      The committee particularly commends the individuals and organisations it has met on its visit to the Kimberley region of Western Australia, upon whom the delivery of services in remote communities depends.

Senator Rachel Siewert
Chair

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