Staffing decisions within a residential aged care facility are influenced by a range of factors. This includes the model of care used and level of resident need in a facility, which can impact both the number of staff and mix of skilled and non-skilled employees. The care needs of residents also determine the level of funding provided through the Aged Care Funding Instrument (ACFI), which can affect staffing decisions.
Despite these variances, implementing a mandatory minimum level of staffing and/or skill mix may help to ensure quality and safety across the aged care sector. On the other hand, mandating a set staffing level may stifle innovation, and even lead to some ‘high performing’ aged care facilities to reduce their staffing levels.
The Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 (the Bill) does not mandate minimum staffing levels or mix of skills. Rather, the Bill seeks to introduce the mandatory disclosure of staff to resident ratios by staff category. These categories provide some information on the range of skills and services available in aged care facilities, although issues were raised about the level of detail needed to ensure consumers could make informed decisions.
Other jurisdictions already have systems in place for the disclosure of information related to residential aged care facilities, including staffing information. This includes the United States of America (USA) and the United Kingdom of Great Britain (UK), both of which could provide useful reporting models for Australia to consider.
Models of Care
The aged care sector employs a range of care models. Hall and Prior Health and Aged Care Group (Hall and Prior), for example, advised that it offers a ‘highly-clinical’ model of care that involves ‘24-hour registered nurse care’ for high acuity resident cohorts. Hall and Prior further stated that the ‘reality is you don’t enter a care home now until you have high care, complex needs.’
Contrasting care in residential aged care facilities to hospitals, the Australian College of Nursing stated that aged care facilities ‘are homes where people are living.’ The Aged Care Industry Association advised that non-nursing staff can address quality-of-life and ‘whole person’ needs through work that includes the provision of ‘food, excursions, [and] in-home activities’.
HammondCare was concerned that the Bill could ‘potentially disadvantage’ its ‘dementia-specific cottage model of residential aged care’, which has fewer residential nurses and more personal care attendants, specialised dementia carers and care staff to residents overall than ‘more conventional’ aged care homes. HammondCare explained that the Bill:
… does not clearly show that the cottage model has an overall higher ratio of care staff to residents than most standard aged care homes. This is an important measure that is meaningful to prospective consumers.
As such, HammondCare recommended any publication of staffing ratios ‘consider the overall care staff to resident ratio and give consumers the opportunity to understand more about different models of care and the evidence behind them.’
Dementia Alliance International advised that its ‘members generally see the emergence of the “Dementia Villages” as an expensive avoidance of providing best care’. Similarly, the New South Wales Nurses and Midwives’ Association (NSW NMA) stated that its ‘members are concerned that aged care providers are attempting to introduce non-nursing models into residential aged care facilities as a cost cutting measure.’
Subsection 9-3C(8) of the Bill allows a 250 word ‘explanation by the approved provider in relation to any ratio notified.’ Aged and Community Services Australia (ACSA) raised concerns that ‘consumers may not avail themselves of the accompanying text, or that the word limit won’t allow for detailed explanations of all the variables that impact on a provider’s staffing level in a way that will assist consumers' understanding.’
Funding and Delivery of Care
Leading Age Services Australia (LASA) advised that staffing allocations in residential aged care facilities ‘are influenced by the levels of funding provided under the ACFI.’ Catholic Health Australia outlined the impact of ACFI funding on staffing and stated that ‘a service with an average daily ACFI payment of $160 per resident per day will have a very different staffing profile to one of a similar size with an ACFI payment of $190 per resident per day.’
UnitingCare Australia also stated that ‘flexibility around staffing is more limited than services would prefer, being highly dependent on the ACFI model of funding.’
Some residential aged care providers indicated that, in addition to ACFI funding, they have relied on their own resources to maintain their staffing levels. UnitingCare Australia stated its current capacity to provide a ‘model of quality care … depends on the draw-down of church and community resources.’ Hall and Prior advised it had created ‘efficiencies in non-direct care areas, but this cannot continue indefinitely.’ Hall and Prior further advised that smaller providers cannot achieve these efficiencies as ‘labour is 85 per cent of their costs.’
Hall and Prior stated that the Bill may place an expectation on aged care providers to increase their staffing levels, which would require additional government funding. Hall and Prior explained:
[The Government] cannot ask providers on one hand to improve the number of staff on the floor of an aged care home, but then continue to reduce the funding available that would pay for those staff members’ wages and assist us all to attract and retain a motivated workforce.
The Council on the Ageing (COTA) Australia considered that an increase in staffing hours would need to be funded by increased ‘government subsidies and consumer contributions.’ The COTA Australia highlighted the 2018 Aged Care Workforce Strategy Taskforce report A Matter of Care–Australia’s Aged Care Workforce Strategy, which outlined the potential cost:
StewartBrown estimate that the effect of legislating direct care staffing hours to 4.3 hours per resident per day would increase care staffing costs by an overall average of $53.09 per bed per day ($19 379 per bed per annum, currently estimated to be a 20 to 25 per cent increase in total costs for organisations).
The Australian Nursing and Midwifery Federation (ANMF) suggested that costs associated with additional funding for increased staffing levels could partly be offset by gains from reducing ‘ambulance transfers [and] unnecessary hospital admittance’. In addition the ANMF stated that there is ‘approximately $400 million of wastage in the system because of staff turnover and related issues’ which could be addressed.
Minimum Staffing Levels
The Australian Medical Association (AMA) considered that the publication of staff to resident ratios should be accompanied by the introduction of a regulated minimum staff to resident ratio (arrived at through consultation). The AMA stated:
… publishing staffing ratios alone may potentially result in setting a ‘poor standard’ of staffing as the commonly accepted ‘minimum’. Whereas a regulated minimum staff ratio, developed in consultation with the medical profession and other key stakeholders, would prevent this … A regulated minimum will, in our strong opinion, still allow [residential aged care facilities] to find innovative ways to care for their residents, through a different mix of staff, above the minimum ‘safety net’ of staff required.
National Seniors Australia similarly stated that many of its members ‘would like to see minimum staffing ratios instituted within residential aged care.’ The ANMF also supported mandatory ratios, in part to address its concern that ‘the number of registered nurses and enrolled nurses have noticeably decreased in many aged care facilities’ despite increasing complexity of care requirements among residents.
The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) also made the point that ‘numbers do matter’, as there ‘is a minimum level which guarantees safety.’
Ms Helen Hardy stated that introducing staff ratios (and increasing the number of staff) ‘is not all about extra duties being carried out [by staff], it is about care being carried out appropriately’. Ms Hardy stated that currently, registered nurses are ‘rushed with an impossible workload’, and often residents are unable to locate a staff member when they need assistance. Ms Hardy further stated that if Australia wants ‘to continue to have recognised first class care facilities, we need to improve staff ratios.’
Hall and Prior supported the development of a mandated staff ratio that reflected acuity of residents and was accompanied by adequate funding. Hall and Prior stated that it would:
… encourage the Government to mandate a researched and thoughtful staffing ratio sensitive to the assessed acuity of residents within the home using the existing [ACFI] tool. This will ensure that adequate care hours are delivered across the appropriate skillsets of staff for the band of acuity that aged care home is assessed to have. … We make this request in the good faith that the corresponding pool of aged care funding supports the staffing ratio that is mandated after due financial modelling and analysis.
The ANMF stated that it was aware of concerns that mandated staffing levels may be a ‘blunt’ instrument, which could have the effect of increasing the number of unqualified staff in aged care. The ANMF addressed these concerns by highlighting that any minimum staffing level would need to be applied flexibly, with a staged approach and with an acknowledgement of skill levels and distribution. The ANMF stated:
… [ratios are about] … setting a mandated minimum staffing level, setting a floor, that can be flexibly and innovatively applied across a facility, or a range of facilities, to ensure care needs are met … In the jurisdictions in the country where we already have nurse-to-patient ratios they have taken several years to implement. You do it in a particular staged way. You also need to meet workforce supply and development … With the ratios, there need to be the right qualifications and the right number of staff, appropriately distributed.
Aged Care Matters highlighted that staff ratios are used in hospitals and child care centres in Australia. In addition, Aged Care Matters highlighted staffing studies from Canada, the UK, Germany, Norway and Sweden which indicated that ‘the ratio of registered nurses-to-residents has a positive impact on the standards of care in an aged care home’, and that ‘residents have better outcomes when registered nurses are on duty.’
In contrast, the COTA Australia and UnitingCare Australia did not support the introduction of mandated minimum staffing ratios, and stated that the evidence to support this approach was inconclusive. The COTA Australia further stated that ‘there is evidence that a mandated staff ratio can lead to facilities which have staffing above minimum ratio levels deciding to reduce their staff, thus impacting negatively on residents in other ways.’
As an alternative to mandatory minimums, the COTA Australia advised that it supported ‘a more qualified workforce with the right skills mix’, with ‘improved training, skills development and remuneration.’
Staff Skill Mix
A mix of skills among the staff of residential aged care facilities was another important consideration for inquiry participants. The Queensland Nurses and Midwives’ Union highlighted research which outlined that minimum care requirements in residential aged care facilities should include a ‘skill mix requirement of 30 per cent [Registered Nurse], 20 per cent [Enrolled Nurse] and 50 per cent personal care worker.’
The LASA stated that ‘the mix of staff is as important to determining the level of care as absolute staffing numbers’. The COTA Australia added that the capabilities of staff are important to consumers, as ‘staffing skills, levels and qualifications are among the most frequently requested information from consumers about residential aged care facilities.’
Braemar Presbyterian Care proposed that ‘a regulated minimum staffing mix … is an important requirement for residential aged care in Australia.’ The ANMF stated that it had been advocating for legislated minimum staffing levels and mixes.
Staffing Categories in the Bill
Palliative Care Australia supported the breakdown of staff by categories in the Bill, as ‘the skill mix also is a key consideration.’ Subsection 9-3C(5) of the Bill outlines ten staff categories to be included in notification of staff to care recipient ratios:
registered nurses level 1;
registered nurses level 2;
registered nurses level 3;
registered nurses level 4;
registered nurses level 5;
nurses with a certificate IV or an equivalent qualification;
personal care attendants;
The Department of Health highlighted that the information presented by these ten categories needed to be useful for consumers and stated:
It would need to be considered whether this level of detail would be useful to consumers and, if so, what additional information and context would need to be provided to consumers to assist in their understanding and choice making.
UnitingCare Australia was of the view that these categories should be flexible enough to account for change within the aged care sector and stated:
… the aged care sector is in a state of flux and increasingly will offer a greater range of options for consumers. To reflect the sector’s desire for innovation, details of any reporting should be enacted through delegated legislation to enable inclusion of new work classifications, rather [than] in the [Aged Care Act 1997] itself.
A number of additional staffing categories were suggested for inclusion in this list to ensure they continued to be prioritised. The NSW NMA recommended that the position of Director of Nursing be included, as ‘facilities where this level of clinical oversight is lacking tend to have poorer clinical outcomes’. The Quality Aged Care Action Group (QACAG) agreed and added that Assistants in Nursing be included. The QACAG outlined the importance of these categories and stated:
… we note there is no mention of the Director of Nursing title, or Assistant in Nursing. Unless we ensure these roles are acknowledged through legislation we risk losing them. Clinical governance of a residential aged care facility can make the difference between quality care and care failures. We need to ensure the role of the Director of Nursing remains integral to the staffing mix.
The Royal Australian College of General Practitioners also emphasised the importance of clinical governance within aged care settings and stated:
Appropriate clinical governance, especially appropriately clinically staffed [residential aged care facilities], has the potential to reduce negative health outcomes by focusing on prevention and management rather than escalation to acute settings, especially referrals to ambulance and hospital emergency departments at night.
The LASA questioned whether the five levels of registered nurses needed to be captured individually and stated that ‘listing registered nurses by the level they are employed under gives consumers very little insight into their actual contribution to care.’ The ANMF recommended that the five levels of registered nurses be removed and replaced with a single ‘registered nurse’ category.
Another option was put forward by the NSW NMA, which recommended the five registered nurse categories be removed and replaced with the categories: ‘Director of Nursing’ and ‘the number and designation of registered nurses at all levels including specialist nurse and nurse educators’.
Hall and Prior was concerned that the Bill may create a ‘perverse incentive … that would reduce expensive registered nurse labour hours to have ratios that look better, but care programs that are poorer for this redirection of funds.’ As such, Hall and Prior stated that:
… more must be done within the Bill to protect the registered nurse-led care model in care settings that have high acuity as they may not compare favourably to lower acuity aged care homes that are front-loaded with less qualified workers.
The ANMF and COTA Australia recommended the category ‘nurses with a certificate IV or an equivalent qualification’ be removed. The ANMF stated that inclusion of this category was ‘unnecessary and potentially confusing’, as staff with a certificate IV could be accounted for under either the ‘enrolled nurse’ or ‘personal care attendants’ categories.
The ANMF also recommended that to provide further clarity, the category ‘personal care attendants’ should be amended to read ‘personal care attendants/assistants in nursing (however titled)’.
Allied Health Professionals
The AMA considered that more information on the roles and mix of allied health professionals was needed in the Bill to inform consumer decision making. The AMA explained:
Allied health professionals are an essential part of the aged care workforce and their availability is crucial to resident care. The different types of allied health professionals should also be categorised, as older people may seek certain types of allied health support when choosing their [residential aged care facility].
Allied Health Professions Australia (AHPA) was also of the view that a single ‘allied health staff’ category does not provide transparency for consumers regarding the specific allied health services on offer at a particular facility. The AHPA stated:
The broad term ‘allied health’ encompasses a number of very diverse professions and its use can act to the detriment of consumers seeking clarity about the services that are available. For example, while a facility might provide good access to physiotherapy staff, it may not have speech pathology services. However, a consumer may simply assume that a broad range of allied health services are available.
The ANZSGM also made the point that both the ‘allied health staff’ and ‘other staff members’ categories covered a diverse range of professions, and that medical professions also needed to be accounted for. The ANZSGM explained:
… not only is that 'other staff' descriptor a problem but so is the descriptor of 'allied health staff' and lumping all allied health staff into one category when you're covering disciplines as diverse as physiotherapy, occupational therapy, speech pathology, nutrition and dietetics. They're all very distinct specialties that do very different things, and I think there are problems with lumping them together. But also, in terms of disclosure of staffing, some recognition of availability of medical professional input as well, whether it be primary care or specialist medical care.
Other Staff Categories
The LASA considered that ‘Recreational Activity Officers’ or ‘Lifestyle Coordinators’, which facilitate the participation of aged care residents in activities, should be listed as a separate category. The LASA stated that this would more accurately reflect the ‘significant contribution to care recipients' quality of life’ that these staff members provide. UnitingCare Australia similarly suggested a new category be created which would include ‘Personal Care workers, Team Leaders, Assistants in Nursing, Therapy assistants, Lifestyle and Recreational staff.’
UnitingCare Australia recommended that the ‘other staff members’ category be expanded. UnitingCare Australia suggested that this category may include ‘chaplains/pastoral care workers, property/maintenance staff and hotel services staff.’
Reporting systems for residential aged care sectors that are in place in other countries were highlighted by inquiry participants. HammondCare drew attention to the USA Government’s ‘Nursing Home Compare’ website, which publishes information on staffing levels in individual aged care homes, as well as other factors that influence care. HammondCare stated:
The [Nursing Home Compare] site presents a staffing score for each home, based on comparisons of the ratio of residents to staff in various categories with state and national averages. As well as the staffing score, each care home is also given a score for health inspections, quality measures and an overall rating, providing a broader context for the staffing information … The US experience makes it clear that staffing levels on their own, provide an incomplete picture of care and must be presented in a broader context.
Aged Care Crisis compared the USA’s system to Australia’s and stated:
… the USA, which has recommended minimum levels and publishes detailed staffing data, has seen a slow increase in staffing levels so that their average level is now almost equal to their minimum recommended level. This is over an hour (one third) more nursing care than the average resident in Australia gets and double the amount of care by trained nurses.
Aged Care Matters highlighted that ‘the USA is the only country that routinely analyses data on staffing and quality indicators.’
HammondCare outlined the UK’s Care Quality Commission and described it as ‘one of the best [rating systems for care homes] in the world.’ The UK Care Quality Commission does not publish staff ratios, but instead ‘considers staffing among a broader range of safety quality measures.’
Estia Health stated that given reporting systems are already in place internationally, ‘there doesn't need to be a redevelopment of work that's already been done in other jurisdictions’ in Australia. Estia Health further explained that using these international examples could hasten the development of a system to publish broader measures of quality and care in aged care, as opposed to only publishing the staff to resident ratio measure as proposed in the Bill.
Levels of staffing and the mix of staff skills within a residential aged care facility are important aspects of determining the quality and safe care of residents. There are also a range of additional factors that can impact the care provided and the number and mix of staff that is needed. These include: the levels of resident need, the location and layout of a facility, and the model of care being provided.
Given this range of factors, the Committee acknowledges that staff numbers alone are not enough to guarantee quality care. Indeed, the Committee heard that the Oakden Older Persons Mental Health Service, which is well known for its complete failure in the provision of care, had a high staff to resident ratio.
Nevertheless, the Committee is of the view that there is a minimum level of staffing that is required if quality care is to be consistently provided. In its recent Report on the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia, the Committee recommended that a minimum of one Registered Nurse be on site at all times in residential aged care facilities.
The evidence received by the Committee in its current inquiry continues to support this previous recommendation.
The Committee heard concerns from aged care providers that the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 (the Bill) may create consumer expectations that residential aged care facilities will increase their staffing levels. The Committee acknowledges that staffing is highly dependent on funding provided by through the Aged Care Funding Instrument and that this is an important consideration for the Government moving forward.
The Committee was interested to hear about reporting systems in place in the United States of America and the United Kingdom of Great Britain that allow for a broad range of information related to residential aged care facilities to be publicly available for consumers. Australia’s reporting system appears to fall short in comparison to these jurisdictions. As such, the Committee considers there is scope to learn from these international examples to improve transparency, competition, comparability and quality within the Australia’s aged care system.
The Committee reiterates the recommendation from its Report on the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia, which is that the Australian Government:
legislate to ensure that residential aged care facilities provide for a minimum of one Registered Nurse to be on site at all times; and
specifically monitor and report on the correlation between standards of care (including complaints and findings of elder abuse) and staffing mixes to guide further decisions in relation to staffing requirements.
The Committee recommends that, twelve months after implementation, the Australian Government review the effectiveness of publishing staffing ratios in improving transparency and consumer choice. This should include consideration of whether amendments are needed to the ten staffing categories outlined in subsection 9-3C(5).
Mr Trent Zimmerman MP
6 December 2018