The Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 (the Bill) aims to increase the availability of information to consumers by publishing staff to resident ratios (staffing ratios) for residential aged care facilities.
Having a sufficient number of well trained staff is a crucial element in the provision of quality care in aged care facilities. In addition, there are other factors that are also important to consumers and these are not included in the reporting requirements outlined in the Bill. The publication of staffing ratios may be more beneficial to consumers if the numbers are contextualised with additional information and explanation.
The preparation of staffing ratio reports may involve additional administration for providers. It is therefore important that any information collected from providers will assist consumers to make informed choices regarding aged care options.
Transparency of the Aged Care System
The Bill will require residential aged care facilities to report information on staffing ratios. Specifically, the aim of the Bill is to create:
... greater public transparency in the provision of residential care services and informing members of the public in any choice they may make regarding residential care services.
The Aged Care Guild suggested that ‘transparency is about providing access to meaningful information that gives clarity on the quality of care provided, assisting consumers to make informed decisions’. The Aged Care Guild added that the Bill was a ‘positive step forward in transparency in the sector’.
The Quality Aged Care Action Group considered that the amendments proposed in the Bill ‘will empower the community to make decisions about which services provide better staffing and skills mix.’ In a similar vein, the Queensland Nurses and Midwives' Union stated that the Bill is ‘an opportunity to provide greater disclosure in aged care’, and will ‘increase transparency of practice and provide public accountability in residential aged care services.’
The Australian Nursing and Midwifery Federation added that the Bill would also increase ‘transparency concerning how government funding is spent by aged care providers’.
In contrast, the Aged Care Quality Association (ACQA) was of the view that ‘the Bill does not create greater public transparency in the provision of residential care.’ Leading Age Services Australia (LASA) similarly questioned whether the Bill would ‘support more informed choice for older Australians when considering their care options’, as ‘every individual’s needs are different and every facility is different’.
The Australian Physiotherapy Association described the Bill as ‘one component of enhancing quality and transparency in residential aged care facilities.’ Similarly, the Australian Medical Association (AMA) suggested that this Bill should only be the first step in reforming the aged care sector. The AMA stated:
… whilst we are very supportive of this Bill, we see it as only the first small step to reforming our aged care system. It lays down the basic groundwork. But we need to pay attention to training, pay, morale, appropriate regulation and not just red tape, supporting adequate medical care, quality end-of-life care and minimising unnecessary trips to the hospital.
Individual Experiences of Transparency in Aged Care
Some inquiry participants provided personal accounts of their experiences of the difficulties in making informed decisions about the quality of care in aged care facilities. Mrs Hariklia Nguyen stated that she had ‘never experienced a system so complex and difficult to access consumer related information … in a timely manner as the aged care system’.
Similarly, Ms Liz Turner provided an example of the impact that a lack of transparency can have on aged care residents and their families. Ms Turner stated that she is:
... about to move my mother, a frail, vulnerable 94-year-old with advanced dementia, to her third [aged care facility]. If I’d had the relevant information, [for example] staff ratios, on the two facilities where she received poor care, I would not be in this position.
Meaningful Quality Indicators for Aged Care
Government Standards and Indicators
The Department of Health highlighted a number of government measures, both existing and in development, that are intended to assist consumers in making decisions relating to residential aged care facilities. In August 2017, the Australian Government announced it would begin publishing Consumer Experience Reports for residential aged care facilities. The reports are based on a survey of approximately 10 per cent of residents during the
re-accreditation process for an aged care facility.
Consumer Experience Reports provide qualitative information, including if:
Staff treat residents with respect;
Staff meet the health care needs of residents;
Staff follow up when residents raise things with them;
Staff explain things to residents;
Residents like the food at the facility;
There are staff to talk to when residents are feeling a bit sad or worried; and
Staff know what they are doing.
The Department of Health is developing a new Single Aged Care Quality Framework which will include: new Aged Care Quality Standards (the Standards); arrangements for assessing providers against the Standards; a charter of rights for residents; and the publication of information to help consumers choose aged care providers.
The Department of Health advised that the Standards are intended to focus on ‘quality outcomes for consumers rather than provider processes.’
From 1 July 2019, the Standards will come into effect and ‘providers will be required to demonstrate that their care and services are safe and effective, and delivered in accordance with each consumer’s needs’.
From July 2020, the My Aged Care website will publish the performance ratings of residential aged care service providers which will provide a comparison to assist consumers to make more informed choices about providers. The Department of Health described the publication of these ratings as a ‘possible star rating type system’. The measurements devised to assess providers against the Standards are expected to be used in developing this rating system.
In addition, the Australian Government’s National Aged Care Quality Indicator Program (QIP) tracks three indicators of aged care quality: incidence of ‘pressure injuries, the use of physical restraint and unplanned weight loss.’
The QIP is a voluntary program with approximately 10 per cent of providers participating. The Department of Health stated that:
Quality indicator data will be published on the My Aged Care website when the data has been established as reliable and accurate and following stakeholder consultation.
The Council on the Ageing (COTA) Australia stated that the Victorian Government uses these three indicators as part of a larger suite of indicators to measure performance in Victorian aged care facilities.
Staffing Ratios as a Quality Indicator
Catholic Health Australia (CHA) questioned whether staff ratios provided consumers with any valuable information they could use to make decisions about aged care facilities. The CHA stated that ‘staffing ratio data [is] not straightforward for consumers to interpret and, if relied upon, [is] potentially misleading’.
Similarly, the Aged Care Industry Association (ACIA) suggested that staff ratio information, on its own, could ‘create only the illusion of information, not necessarily actual understanding’. As an example the ACIA highlighted the ‘Oakden Older Persons Mental Health Service, which had a very high staffing ratio and lots of qualifications and provided dreadful care’.
The Older Persons Advocacy Network (OPAN) stated that there was ‘limited evidence’ that staffing ratios are an effective quality indicator in aged care settings. The OPAN added that ‘staffing ratios are a contentious and complex matter and this Bill appears to be premature in proposing a solution before an in-depth exploration into the matter has occurred’.
Similarly, UnitingCare Australia was concerned that the reporting requirements in the Bill could have the ‘effect of legislating particular staffing models by default.’ UnitingCare Australia suggested that ‘options for independent review of staffing practices by a body such as the Aged Care Quality and Safety Commission or an external financial auditor should be canvassed.’
The Allied Health Professions Australia (AHPA) expressed concerns with the Bill and stated that staff ratios ‘do not necessarily indicate the quality or appropriateness of care provided’. Despite this, the AHPA supported the passage of the Bill through Parliament suggesting that it would increase ‘transparency for consumers about the staffing resources within residential aged care services’.
The Australian Nursing and Midwifery Federation, while acknowledging that other factors were also important, emphasised the significance of staffing levels, stating ‘numbers do matter ... if you are one registered nurse and you have got 160 residents, numbers matter’.
Contextualising Information for Consumers
The LASA and Aged and Community Services Australia (ACSA) both highlighted that there were many factors other than staff numbers that can impact on quality of care. These factors included: resident acuity, models of care, building design, community volunteers, technology, and services provided by external staff.
The LASA stated that without additional information a staffing ratio could be difficult to interpret and potentially misleading for consumers if they were unable to easily compare facilities or services. The ACSA suggested that ‘a staffing ratio should only be used where it is part of a suite of quality indicators’. The ACSA added:
We recommend Government work with key stakeholders and industry to develop such a suite of quality indicators (that includes a staffing ratio measure) that are evidence based and focus on the quality of care and services that consumers receive.
The provision of extra information that would assist consumers in making ‘like-for-like’ comparisons between residential aged care facilities was supported by Estia Health and COTA Australia.
Furthermore, the Federation of Ethnic Communities' Councils of Australia (FECCA) suggested that the provision of additional information is particularly important for culturally and linguistically diverse consumers who may have a lower ‘knowledge of the aged care systems in Australia’. The FECCA suggested that additional information should include details on how much individual attendance a resident can expect under standard staffing ratios.
The Department of Health suggested that the information provided to consumers should be easy to understand and that ‘any measurements selected and the way they are communicated [be] chosen carefully’.
The Australian and New Zealand Society for Geriatric Medicine (ANZSGM) similarly emphasised the importance of how data is presented to consumers and proposed the development of a ‘quality and safety dashboard’. The dashboard could provide information relating to a facility’s:
Access to primary care (both in-hours and out-of-hours);
Access to specialist services;
Use of hospital admission and ambulances, including out-of-hours; and
Number of facility acquired complications.
Acuity of Care
The AMA stated that a staffing ratio indicator risked being misunderstood if it was not ‘contextualised by data on the level of care needs of the [residential aged care facilities’] residents.’ The AMA added that production of information on level of care needs ‘is not an onerous requirement on the industry’.
Hall and Prior Health and Aged Care Group (Hall and Prior) added that ‘publishing existing staff ratios without context for complexity of the needs of the people they care for will … drive staffing to the lowest acceptable level to the community’.
Hall and Prior explained that residents in its facilities require high levels of care and that it therefore invests in ‘highly skilled clinical teams’ that are shared across multiple facilities. Hall and Prior was concerned that these staff members would not be captured in staffing ratios for its facilities. By contrast:
... the staffing profile for an aged care home with much lower acuity than ours would be much more represented by direct care workers, service attendants, and people performing social care duties. These types of roles are typically direct-employed by the care home ... and so would be represented in the care ratios, making these ratios appear to be much lower than a more highly acute home [with] a workforce with much higher clinical skills like ours.
The COTA Australia suggested that the publication of staff ratios should be accompanied by the publication of a resident acuity measure, drawn from Aged Care Funding Instrument (ACFI) data already available to the Department of Health.
The Australian College of Nursing also recommended using ACFI data, describing it as a ‘cumulative total measure of resident acuity within a particular facility at a specific point of time’.
Calculating Staff Numbers
The LASA expressed concerns in relation to the requirement, specified in subsection 9-3C(4) of the Bill, for staff ratios to be reported for four days across the year. The LASA stated that ‘staffing levels vary somewhat from day to day’ and therefore it proposed that a full time equivalent staff average calculated across a six week period be used for each of the four reporting periods.
The ACQA highlighted that one of the four dates specified in subsection 9‑3C(4) is 1 January and that ‘many facilities have residents on social leave for the Christmas or New Year period and therefore will reduce staff’. The ACQA explained that this may trigger the additional reporting outlined in subsection 9-3(9), stating that:
Routinely reporting staffing levels if they fall on a weekend or public holiday will require numerous unnecessary reports to the Secretary. There will be a deviation in staffing numbers as soon as a ‘normal working day’ is worked, not necessarily in larger homes but certainly in smaller rural and remote organisations.
The Western Australian Government stated that rather than specifying notification dates a ‘more appropriate way’ of capturing staff numbers and categories could be through the unannounced audit program.
The Western Australian Government highlighted that the Bill does not account for fluctuations in staffing levels on weekends or during the night. This could have the consequence of aged care facilities reporting ‘a high number of [staff] at a certain time of the day but not [having] adequate staff coverage at night or peak times’.
National Seniors Australia (NSA) added that there are different staffing requirements during different parts of the day with ‘workloads heaviest in mornings and during meal times when residents require intensive assistance but less at night time’. The NSA added that it was aware ‘of instances when low staffing levels in periods of low demand, such as at night, result in substandard care for residents’.
The COTA Australia made a similar point stating that the daytime is ‘not the time that consumers are worried about, consumers, particular around high‑clinical-care needs, want to know [if] there is a nurse overnight’.
The ACIA highlighted that the definition of staff in the Bill included short-term agency staff. The ACIA stated that:
... use of large numbers of agency staff in a facility would therefore support high reported staff numbers—but it is conceivable that use of a small number of long-term staff, who are more familiar with and to residents, would provide improved services and more confidence to residents and families.
Financial and Regulatory Impacts
The AMA cautioned that the Bill should not impose any ‘unnecessary [regulatory] burden upon these already stretched facilities’. The AMA added that any ‘time spent on compliance is time that cannot be spent actually looking after people’.
The Department of Health suggested the requirement under subsection 9‑3C(9) of the Bill would ‘increase administrative costs and regulatory burden’ for providers. Similarly, the New South Wales (NSW) Government stated that quarterly reporting was ‘sufficient to provide a clear view of the staffing ratios in individual facilities’. The NSW Government added that, for small providers, the additional reporting of a 10 per cent staffing change may result in a situation where ‘one or two staff leaving and being replaced could trigger a reporting requirement for an insignificant and temporary situation’.
The ACQA also questioned the requirements of subsection 9-3C(9). The ACQA suggested that consistent monitoring of staffing ratios to identify changes would be ‘particularly onerous on small rural and remote facilities that do not have [the] economy of scale ... to produce this information on either a daily or weekly basis.’
More broadly, the ACQA stated that the provision of staffing ratio data created an administrative burden because it cannot be completed ‘rapidly from a payroll system, because there would be a lot of service providers who come in on a contract basis or a fee-for-service basis who are not paid directly out of a payroll function.’
In a similar vein, the AHPA suggested that reporting on allied health professionals would be difficult as they are generally ‘either employed by a group of facilities which makes allocation of hours complex, or they are contracted on a sessional or as needed basis’.
In contrast, Mrs Hariklia Nguyen commented that staffing data is ‘already collected and reported regularly’ by aged care facilities. As such, Mrs Nguyen questioned whether the Bill would create an ‘additional administration cost’.
The Department of Health, considering the regulatory cost to government, stated that:
... there will be costs to design and implement the solution to publishing staffing ratios on the My Aged Care website. There are also likely to be ongoing costs for Government and aged care providers in collecting, collating and publishing the information proposed by the Bill.
Monitoring and Improvement
The Australian College of Nursing and COTA Australia both suggested that the Aged Care Quality and Safety Commission should be responsible for checking staffing rosters of aged care facilities to monitor the accuracy of data reported by providers.
The ACQA advised that it had created a ‘quality platform’ that its members could use to benchmark their performance against other facilities with similar levels of ACFI funding. Providers who subscribe to the platform can compare their performance based on criteria such as ‘medication, incidences, falls, skin integrity issues and behaviours of concern’.
The Department of Health advised that it is developing a risk profiling algorithm that is intended to assist the Government with identifying which services might have higher risk and which services you might visit [for site audits] sooner and more often’.
In recent years a number of inquiries, including the Committee’s own Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia, have shown that there is a pressing need to increase the level of transparency in the aged care system. Increasingly, the experience of deciding to place a family member into residential care is made when the elder person’s care needs have become acute. Consumers are often faced with the need to quickly make a difficult decision about the suitability of different care facilities. Yet they have little independently verified information to help them make an informed choice.
Even if a consumer is only looking for a hotel for a single night, each hotel they consider will have many, often hundreds of, reviews as well as ratings against criteria such as ‘comfort’, ‘cleanliness’, ‘facilities’, and ‘staff’. Given this, you would expect consumers to have access to ample information to assist them make a decision about where a loved family member will live and who will provide their medical support and care in their later years of life. Unfortunately this is not the case.
From the evidence received, the Committee does not believe that, on its own, the publication of staffing ratios will provide the necessary transparency to enable consumers to make informed decisions or increase the quality of care provided to aged care residents. Indeed, the Committee has previously, in its Aged Care Report, recommended the development of a broad, consumer‑oriented, rating system. The Committee reiterates this recommendation and urges the Department of Health to continue to work with the aged care sector to develop a rating scheme for residential aged care facilities.
Despite these limitations, the Committee supports the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 (the Bill) as it will increase the amount of information available to consumers. It may only be a minor step, but it is a first step.
Consumer advocacy, peak organisations, and individuals (including those that supported the Bill) made suggestions regarding how the Bill could be improved. The Committee agrees that minor modifications to how staffing ratios are reported could significantly improve the quality of information provided to consumers.
A major issue raised is that the proposed method of reporting staffing ratios does not take into consideration differing levels of resident acuity. Facilities that predominantly care for residents with highly acute medical needs may, and usually will, have higher staffing ratios. It does not follow, however, that a potential resident with less acute needs would be best suited to this type of care rather than an aged care home with a greater emphasis on quality of life activities.
The Committee recommends that the Department of Health consider how resident acuity levels can be presented alongside facility staffing ratios when this data is published. The Committee believes that reported staffing ratios need to be accompanied by additional data, in order to enable consumers to make like-for-like comparisons between facilities.
The Bill currently does not account for fluctuations in staffing numbers between day and night or due to weekends or public holidays. Ensuring that residents have access to registered nurses at all times, and especially overnight, is a key concern of many consumers.
Additionally, the requirement for providers to report changes to staffing ratios of greater than 10 per cent between reporting periods may create an unnecessary regulatory burden. This may be particularly likely in smaller rural and remote facilities where a temporary absence of just a few staff members could initiate a reporting requirement.
Given these concerns, the Committee recommends the Department of Health monitors the effectiveness of the Bill in relation to staffing on weekends and at night, and additional reporting requirements. If monitoring shows these sections of the Bill are not operating as intended, the Government should consider further amendments to the Aged Care Act 1997 (Cth).
The Committee also received evidence that the Government’s voluntary National Aged Care Quality Indicator Program is only being used by approximately 10 per cent of providers. The Committee reiterates the recommendation it made in its Aged Care Report that this program be expanded and made mandatory.
The Committee recommends that the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 be passed by the Parliament.
The Committee recommends that the Department of Health publish the staffing ratio data specified in the Bill in a form that allows consumers to consider resident acuity levels when comparing facilities.
The Committee recommends that, should the proposed Bill be passed, that for twelve months following the implementation of the Bill, the Department of Health monitor (and make legislation and other adjustments where necessary), the effectiveness of:
subsection 9-3C(4) with a view to whether there is a need to report on staffing ratios at night and on weekends; and
subsection 9-3C(9) with a view to whether this clause creates an unnecessary reporting burden, particular for smaller facilities.
The Committee reiterates the recommendation from its Report on the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia that: the National Aged Care Quality Indicator Program:
be made mandatory for providers of Australian Government-funded residential aged care services; and
be expanded to include a broader range of key indicators, to be determined with the involvement of the aged care sector and consumer groups.