There were a lot of new ideas and informative debate at yesterday’s Aged Care Reform Conference in Melbourne, but a panel discussion regarding one particular topic highlighted the disconnect between those that work and live in aged care and those that govern it.
From the outside looking in, the idea of mandated staffing ratios in aged care seems like a no-brainer.
Residents and families want it, aged care employees want it, and polls on HelloCare show that an overwhelming percentage of our audience also feel that it is something that would benefit both residents and staff.
Despite all of this though, there is no indication of ratios being mandated on a federal level – and excuses from the government, providers and peak bodies appear to be thinly veiled.
Yesterday’s panel discussion featured four guest speakers including ANMF Federal Secretary, Annie Butler, Anita Volkert from Occupational Therapy Australia, Professor Christine Sterling from the University of Tasmania, and Geriatric Medicine specialist Dr. Toby Commerford.
Even though each panel member had their own specific area of expertise, the support for staffing ratios was unanimous and complemented by various insights.
“The ANMF has been calling for mandated minimum staffing levels and skill mixes for years now,” said Annie Butler.
“We support giving staff the right training and education, but you can be the most highly qualified nurse on the planet with the best attitude and attributes, if you’re responsible for looking after 157 people, it’s not going to matter. Numbers matter.”
The rest of the panel echoed Annie’s sentiments, and Professor Christine Sterling provided some insight into where she believes the pushback from aged care providers is coming from.
“I think mandated ratios of the right mix of staff is vital,” said Professor Sterling.
“Obviously, there is more to any improvement than just numbers, but there is a fundamental underpinning that if you don’t have the numbers then all the quality in the world will not compensate.”
“I think that there’s a lot of pushback and qualifying around that is partly underpinned by a concern that some sort of mandated ratio won’t be supported by accompanying funding.”
“I think the main fear is that the sector will be forced to have a ratio imposed upon them even though many are already losing money.”
Skills mix and education
At present, 71.5% of the residential aged care workforce is comprised of personal care assistants, who are the lowest paid and least qualified people within the aged care workforce.
The overreliance on PCA’s has increased steadily over the last 15 years while the amount of registered nurses and enrolled nurses in aged care has dropped dramatically over the same time period.
Currently, Registered Nurses make up 14.9% of the residential aged workforce, while Enrolled Nurses (9.3%), and Allied Health Professionals (1.1%), and Allied Health Assistants (2.9%), make up the rest.
Some may even argue that the current skill mix is being dictated by who costs the least, as opposed to what will deliver the best outcomes.
According to Dr. Toby Commerford, specialist care services are not represented anywhere near as much as they should be in the aged care space.
“Semantically, if you think of the phrase ‘nursing home,’ there’s very few nurses because there are no ratios, and they’re not necessarily the kind of home that someone wants to go into,” said Dr. Commerford.
“People are coming to residential facilities very unwell, and it’s nuts that the specialists like us that deal with that like us can’t get in, so ratios do matter a lot, but it’s just what you do with it.”
“I feel like we should have around the clock geriatrician input for residents in nursing homes, to the point that we almost start to change the concept of it being a nursing home and becoming a hospice.”
“People are going into homes at the end of their life, they’re not much different from geriatric wards and hospices, so if we changed the semantics around it, and it became funded like hospital then it would be compulsory to have specialists there.”
“The Royal Adelaide Hospital can’t just have no geriatricians. So, if the nursing home down the road was viewed in the same way then that would force specialists into these homes.”
The Cost Of Ratios
Research that was commissioned by the ANMF and conducted by the University of South Australia and Flinders University concluded that the ideal skill mix required for care was starkly different from the mix we most commonly find in aged care homes today.
The research found that a best-case scenario on average would comprise of a workforce made up of 30% registered nurses, 20% enrolled nurses, and 50% personal care workers.
Annie Butler declared that over time, she believes this process would become cost-effective given the amount of money currently being lost to staff turnover and the cost of constant hospitalisations.
Anita Volkert was also critical of the current skill mix in aged care and called for a more proactive approach to addressing the needs of people as they enter old age.
“Yes, numbers definitely do matter but it’s not just a numbers game, you can have as many people working in residential aged care as you like, but unless you have quality engagement, it makes no difference at all,” said Anita.
“If we approach ageing with a more preventative focus and put our staffing resources into wellbeing early in peoples ageing journeys we see quite a cost-benefit down the track, but that requires investment and a skill mix that we currently don’t have at the moment.”
Over the years we have heard a variety of Ministers and peak body representatives refer to staff ratios as a ‘blunt instrument’ in an attempt to try and convince the masses that having no minimum staff numbers equates to flexibility.
Quite often, questions regarding ratios are met with rhetoric that all aged care facilities are different and that each facility needs the ‘right’ amount of staff to meet the needs of its residents.
While it is true that facilities do need the right amount staff, the fact of the matter is, aged care providers have differing views on what that is, and the Interim Report highlighted that facilities are understaffed and have staff who are overworked.
The other common rebuttal to staffing ratios is switching the focus to the education of aged care staff and upskilling those in carer roles, and some panel members were cautious about where that road may lead.
“One of the things that does concern me is that I keep hearing that we need to increase the training of care workers, which, yes, we do, but sometimes you think, are they going to try and get care workers and train them up to do the same things as a registered nurse?” said Professor Stirling.
“Let’s not allow the current situation to prevent us from seeing (ratios) as a clear need and solution.”
“We all know that people are getting sicker and that there is more acuity, yet over the last decade there has been a decrease in the clinical expertise of the staffing in aged care facilities and in the community sector.”
No money, no problems
Annie Butler shared the same concerns as Professor Stirling regarding the upskilling of carers as opposed to utilising nurses and specialists, and she was rather forthright when asked about the true reason that we haven’t seen staffing ratios in aged care.
“Money. The pushback purely comes down to money,” said Annie.
“Aged care facilities that are struggling like rural and remote places are not given any money and the big providers pinch in from them, but the bottom line is – the government doesn’t want to fund it.”
“I think most people would pay more tax for better care, but they would some evidence regarding how that money is being spent. And that’s why we need minimum staffing ratios and appropriate skill mix so that people can tie their tax dollars to care.”
“We (ANMF) would also argue that some of our tax dollars now are not going to the best things right now that should be relocated.”
A recent poll conducted by HelloCare showed that the majority of our audience would be willing to pay more taxes if they could be assured that it was being used effectively to provide better care.
Whether or not this is an option that the government has considered remains to be seen.