Witness Statement to the Royal Commission into Aged Care Quality and Safety

Publication published 7 February 2019

Witness Statement to the Royal Commission into Aged Care Quality and Safety

  1. This statement made by me accurately sets out the evidence that I am prepared to give to the Royal Commission into Aged Care Quality and Safety.
  2. This statement is true and correct to the best of my knowledge and belief.
  3. I make this statement on behalf of Combined Pensioners and Superannuants Association of NSW Inc (CPSA) and I am authorised to do so.

Professional background

  1. I am the Policy Manager for CPSA. I have been in this role since early 2006 with a hiatus between 2008 and 2010 when I worked in a similar role for National Seniors. I also worked at Spinal Cord Injuries Australia in a similar role from 2004 to 2006. I am a linguist and accountant by qualification and am experienced at policy research and development and advocacy.
  2. CPSA is a non-profit, non-party-political membership association founded in 1931 which serves pensioners of all ages, superannuants and low-income retirees. CPSA has 73 branches and affiliated organisations with a combined membership of 17,000 people living throughout NSW. CPSA’s aim is to improve the standard of living and well-being of its members and constituents. CPSA receives funding support from the NSW Government Department of Family & Community Services and Health and the Australian Government Department of Social Services.
  3. As Policy Manager I report to the General Manager of CPSA. I research policy issues that arise and advise the CPSA Executive on policy as part of its deliberations on what the appropriate policy position is for CPSA in a set of given circumstances. I also function as CPSA’s spokesperson at inquiries and in the media.
  4. I note that I have never been employed by, or involved with an Australian or overseas aged care provider.
  5. I note that this statement responds to all topics listed in the Notice to Give Information or a Statement In Writing, reference NTG009, dated 25 January 2019, except for topic k) “how might a national culture of respect for aging and older persons be fostered?” CPSA is a small organisation which needs to prioritise its campaign goals. While all CPSA’s campaign and advocacy work contributes to the promotion of a national culture of respect for aging and older people, CPSA has not been able to specifically research and develop policy in this area.

Key issues for the aged care system over the next 20 years

  1. Of all the issues that the aged care system must resolve and manage over the next few decades, none is more important and pressing than aged care safety. The aged care system will have to cope with growth in demand for aged care and will need to continue its switch to the cheaper and consumer-preferred form of home care, considering perhaps the Danish example where in 1988 a moratorium was placed on nursing home construction in order to facilitate this shift.
  2. The system of Government subsidisation of the care component of residential aged care under the Aged Care Funding Instrument will need to be reviewed to ensure adequate funding levels are available while getting a handle on the demonstrated inclination to game funding arrangements by a profit-hungry industry, which, through consolidation and buy-outs, will increasingly be dominated by for-profit providers operating chains of aged care services.
  3. At the same time the aged care system must consider its place among the three other separate main care systems for (1) general health, (2) oral health and (3) disability. It may be time for government to consider full integration of these systems, as has occurred successfully in, for example, Germany and the Netherlands, resolving the inequitable consequences of operating general health and disability systems on the basis of entitlement while the oral health system (excised from general health system) and the aged care system are operated on the basis of eligibility, a euphemism for waiting lists. The definitional split between aged care and disability care is entirely artificial and irrelevant because it is based on the cause or causes of disability, not its effects. As a result, people under 65 in the residential aged care system cannot access assistance under the NDIS, while people over 65 with disabilities cannot access the NDIS unless they registered with the NDIS before they turned 65. The excision of oral health from general health has ongoing, dire consequences for public health, both in terms of health outcomes and budgetary outcomes, and for people of all ages.
  4. However, in the face of all these issues, one issue stands out as one that must be resolved with the greatest of urgency: aged care safety, the minimum level of aged care quality in both residential aged care and home care. It is this issue which has prompted the Royal Commission into Aged Care Quality and Safety and it is this issue that the Royal Commission must resolve.

The objectives of the Aged Care Act 1997

  1. The framing of the Aged Care Act 1997, the main piece of legislation regulating the aged care system, has enabled the intertwining of the interests of the Australian Government and the interests of residential aged care providers’ to the point where consumers have no say in what constitutes safety and quality in aged care and have to accept whatever the aged care system provides.
  2. Section 2.1 sets out the objects of the Aged Care Act 1997 and, significantly, starts out by identifying the provision of funding of aged care as its main objective. This is odd and out of step with what the community expects. Section 2.1 then lists a number of things among which are supply, safety and quality, that need to be considered as part of funding provision, but finishes off on a note of caution to those administering the Act, exhorting them to have “due regard …to: (a) the limited resources available to support services and programs under [the Aged Care] Act; and (b) the need to consider equity and merit in accessing those resources”.
  3. What has the implementation of the objectives of the Aged Care Act 1997 over thirty-odd years produced? At the time of writing this witness statement, the latest published data[1] show that 127,000 people were waiting for the Home Care Package (HCP) at the level for which they had been assessed. Of those 127,000 waiting 69,000 had no HCP at all, but 63,000 of those 69,000 accessed the entry level form of aged care provided through the Commonwealth Home Support Program (CHSP), while of the 127,000 people waiting, 58,000 had a lower level and therefore inadequate HCP.
  4. Of the 127,000 people waiting, 90,000 also had an approval for entry into residential aged care. If all these approvals were exercised, the residential aged care sector would not be able to meet demand, given its latest occupancy rate of 90.3 per cent and number of operational places of 207,142[2]. The combined level of undersupply across residential aged care and the HCPs program is vast and shocking.
  5. It is noted here that the HCP program is a Consumer Directed Care (CDC) program, but that two-thirds of the people in the HCP program are effectively unable to exercise the CDC feature of the HCP program. They can switch provider (this may or may not be subject to an exit fee), but whichever provider they choose will by definition provide inadequate care to those on a lower-level HCP than for which they have been assessed.
  6. The aged care system as it is currently configured, i.e. (1) on an eligibility rather than an entitlement basis and (2) with its massive supply constraints imposed by regulation, is shown up for what it is: a system where consumers must take what they are given if they are given anything at all. It stands to reason that the quality, and more importantly, the safety of what they are given suffers from that.
  7. It is obvious that in order to shift the priorities in aged care from the financial requirements of the Government and financial profitability of approved providers to the care needs of consumers, the Aged Care Act 1997 should be overhauled in favour of consumer rights and needs.

Aged care safety

  1. An improved Aged Care Act 1997 or its replacement would need to acknowledge and reflect the distinction between aged care safety and aged care quality and the fact that quality doesn’t begin unless safety has been assured first.
  2. Aged care quality beyond aged care safety relates to quality of life. Aged care safety includes the basic or minimum components of care, including conditions in which older people in need of care:
  • are safe from abuse and exploitation;
  • are adequately housed;
  • are adequately nourished;
  • receive adequate personal and clinical care; and
  • have adequate access to care equipment and supplies.
  1. However, there is an additional, often-overlooked component of formal aged care safety, viz that older people in need of aged care get access to aged care. Aged care safety does not just apply to people who receive care, it also applies to people who do not receive it but need to.
  2. As shown earlier, access to aged care for all who need it does not exist in this country. Access to aged care falls well short of what is required both in terms of numbers and in appropriate level and quality of care.
  3. What also becomes obvious from the current waiting list statistics is that, effectively, a waiting list existed a long time before an actual waiting list was first published by the Department of Health in September 2017 as the waiting list for the Home Care Packages program, and which only in its last publication in November 2018 puts a number on the waiting list for residential aged care. That number is just under 90,000 as mentioned earlier and overlaps entirely and necessarily with the HCPs program waiting list: no separate list is or has ever been kept for residential aged care.
  4. Instead of a waiting list for residential aged care, the Department of Health used the smoke-and-mirrors approach of the Aged Care Provision Ratio (ACPR). The ACPR is also used to assist in determining the number of aged care places released each year as part of the Aged Care Approvals Rounds (ACARs). The ACPR is an index showing the number of operational aged care places per one-thousand people over 70. The last ACPR target the Department set was 125 by 2021–22. The target for Home Care Packages was intended to increase from 27 to 45, and the residential target to reduce from 86 to 78. In addition, a restorative care target of 2 places was set.[3] The targeted ACPR increases do not represent an attempt to reduce unmet need, but an attempt to keep the aged care market undersupplied at about the same rate: ACPR targets are set to keep pace with the increases in the number of people aged 70 and over.
  5. What the number of 90,000 people approved for residential aged care suggests is that that there is widespread reluctance to enter into residential aged care.
  6. Anecdotally, people with dual approvals for an HCP and entry into residential aged care hang on for as long as they can in an inappropriate HCP or even without one. This observation is supported by evidence of declining occupancy rates in residential aged care. The occupancy rate, which was 93 per cent at 30 June 2014 – when the expansion of the HCPs program received public attention and a year before Consumer Directed Care was introduced in the HCPs program on 1 July 2015 – has declined in every subsequent year and at 30 June 2018 stood at 90.3 per cent.[4]
  7. A 2015 CPSA survey asked the question, “If you needed some kind of aged care, where would you prefer to receive care?” Ninety-five per cent of respondents said they wanted to receive care in their own home, five per cent in a nursing home.
  8. Reluctance to enter into residential aged care is based on concerns held by people about aged care safety components (other than access) and about aged care quality in residential aged care.
  9. The main source of official data about the safety and quality of both residential aged care and home care is the compliance monitoring program administered by the former Australian Aged Care Quality Agency, now the Aged Care Quality and Safety Commission. The Commonwealth Home Support Program is not monitored for safety and quality at all and, anecdotally, the quality and reliability of service is often poor, dependent on the work ethic of individual workers.
  10. When the Prime Minister announced the Royal Commission into Age Care Quality and Safety, he released a single-page, ad hoc report headed Aged Care Regulation in Quality – Activity & Actions containing compliance and compliance monitoring information related to the 2015/16, 2016/17 and 2017/18 years. The findings of non-compliance published in the Aged Care Regulation in Quality – Activity & Actions report show dramatic increases in bad performance for 2017/18 and this served as justification for calling a Royal Commission into aged care. It is remarkable that the Department of Health, its Minister, the Prime Minister, the Australian Aged Care Quality Agency or the Complaints Commissioner or indeed the Aged Care Quality and Safety Commission have omitted to provide an analysis or an explanation as to why such a sudden, apparently dramatic decline in aged care safety and quality occurred in 2017/18.
  11. Departmental staff, Commission staff and aged care providers have provided off-the-record insights into how the statistics for 2017/18 came to show a dramatic increase. It is the result of the tightening of the way performance against the Accreditation Standards are applied following the publication of the South-Australian Chief Psychiatrist’s report on the Oakden Older Persons Mental Health Service in April 2017, which found that the quality of care at that facility was inadequate in all respects. The Oakden Older Persons Mental Health Service, placed under sanctions in 2008, had been assessed as meeting all forty-four expected outcomes required under the Accreditation Standards in 2011 and 2014.
  12. The sudden, apparent deterioration in the performance of the residential aged care sector recorded in the Department of Health’s ad hoc report calls into question the adequacy of how compliance has been assessed since the introduction of the Accreditation Standards. The deterioration is on such a scale that the only conclusion can be that compliance monitoring prior to 2017/18 was broken and under-reported non-compliance because its methodology to find non-compliance was broken.
  13. It is CPSA’s view that there was no sudden, dramatic decline in aged care safety and quality, but that aged care safety and quality has been inadequate for a long time. It is also CPSA’s view that the statistics contained in the ad hoc Aged Care Regulation in Quality – Activity & Actions report may still significantly understate the true incidence of non-compliance with aged care standards in the residential aged care sector. This view is supported by an analysis of the assessment techniques used by the then Australian Aged Care Quality Agency.

Assessment methodology and compliance

  1. How to assess a residential aged care facility’s performance against the four Accreditation Standards and 44 expected outcomes that make up the current quality framework is explained in a publication called the Results and Processes Guide[5]. Together with the Quality Surveyor Handbook[6], which is about the behaviour of assessors, the Guide is the frame of reference for individual assessments of facilities. Both publications were published before the Oakden scandal broke. It is noted here that, at the time of writing this submission, no document similar to the Guide had been published to assist assessors in applying aged care standards from 1 July 2019 as part of the Single Aged Care Quality Framework.
  2. The following are the three methodologies the Guide tells assessors to use to measure performance against these expected outcomes:
  • Obtaining information from care recipients or their representatives;
  • Obtaining information from staff;
  • Obtaining information by examining whether processes and systems are in place and if these processes and systems are effective.
  1. There are some obvious criticisms to be made of these three methodologies.
  2. Obtaining information from care recipients who are compos mentis may be inhibited in their reports to assessors. Those care recipients may be concerned about possible informal repercussions from care workers or the facility itself and they may be inclined to say care is adequate even if it is not. Representatives may be conflicted in stating that care recipients are satisfied with the care they receive. Also, representatives may not know if the care recipient is satisfied. Representatives may also be concerned about repercussions for the care recipient if they say the recipients are not satisfied. Another possibility is that a representative knows that the care recipient is not satisfied, but it may not be in the interests of the representative to express this.
  3. The then Australian Aged Care Quality Agency codified obtaining information from care recipients through the Consumer Experience Reports (CER) process conducted in every residential aged care facility it assessed. The aggregated CER, certainly when read in conjunction with the Aged Care Regulation in Quality – Activity & Actions report discussed earlier, offers some bewildering results. The ten questions all attract majority positive response, the lowest being 81 per cent, the highest 98 per cent. Especially odd is the more than 98 per cent positive response to the question ‘Do you feel safe here?’. The Aged Care Regulation in Quality – Activity & Actions report shows there were 3,773 reportable assaults in residential aged care in 2017/18, a number that excludes repeat assaults and assaults of residents by other residents, and means that residential aged care recipients have a 1.7 per cent chance of being assaulted by a member of staff.
  4. Obtaining reliable information from staff is complicated by the obvious conflict of interest staff have when asked to rate or describe the tangible results for care recipients in their charge. Their responses are a report on the quality of their own work and therefore likely to be biased, while they may feel pressure to not criticise their employer for fear of repercussions. Also, staff could think that, if they indicated dissatisfaction or cause for dissatisfaction on the part of care recipients, it would reflect negatively on their personal performance. Also, staff may not know if care recipients are satisfied.
  5. Obtaining information by examining whether processes and systems are in place is one thing, but judging if these processes and systems are effective is another. The effectiveness of processes and systems may be observed by watching their operation or by checking documents recording their operation. However, assessors cannot watch their operation all the time, they can only spot-check their operation, which means that those processes and systems may only be used by a facility while the facility is beingassessed. As to using records of processes and systems in operation, these records may not be accurate and can show what should have happened rather than what actually happened.
  6. Residential aged care assessors have relied on these methodologies, with the result that assessment processes became ritualistic and their results predictable. Providers knew what to expect in the way of assessment activity and were effectively able to game assessments to the extent that non-compliance went undetected. The ritualisation of assessments has also been aided by the fundamental lack of transparency associated with the existing assessment process. Assessments happen away from the public eye and no external criticism of individual assessments can take place in the absence of information. Not only does this lead to potential meaningless assessment activity, but also to lack of information on the basis of which consumers can make an informed decision about particular providers and services. Making application for this type of information under Freedom of Information legislation is thwarted by what amounts to a blanket exemption from releasing information (section 86.1, Aged Care Act 1997) if it relates to “the affairs of an approved provider”. It is clear that transparency of assessments by the removal of the frankly preposterous definition of protected information in the Aged Care Act 1997 would open up the aged care industry to healthy public scrutiny.
  7. A slight change in assessment practices and deviation from the ritual has produced more accurate results. Before the publication of the Oakden report by the South-Australian Chief Psychiatrist and the tightening of compliance measurement practice that ensued, residential aged care facilities would meet expected outcome 2.10 (Nutrition and hydration) almost without exception, even though study after study had found that the malnutrition rate among residents was upwards of 50 per cent. After Oakden, assessors changed the way they measured compliance with 2.10. Rather than checking past menus and food supply bills, they began to observe the actual mealtime processes and found what was common knowledge among nursing staff, viz that in many cases residents were served food without there being sufficient staff to give assistance to those who needed assistance. This meant that meals were served and taken away uneaten. In this instance, a change in the way compliance was measured led to an accurate result and has earned quite a few facilities the unmet-label for expected outcome 2.10.
  8. However, adding actual observation to the assessor’s armoury is unlikely to be effective over time. It is obvious that those facilities caught once will not be caught out in this way a second time. During subsequent assessments, on short turn-around, facilities will call in more staff to assist at mealtimes and they will once again meet expected outcome 2.10 without really meeting it. The only way facilities can be made to ensure permanent adequate supports during mealtimes is to observe what happens at mealtimes continuously.
  9. This illustrates not only how difficult the task is of measuring compliance, but also how important it is for assessments to focus on objectively measurable outcomes by means of medical assessments, continuous observation using digital video/audio recording and mandatory compilation of quality-of-care indicators. In other words, aged care standards should be integrated with compliance measurement.
  10. There is no point in having standards where compliance with the standards cannot be measured uniformly and objectively. Unless uniform and objective compliance measurement is built into aged care standards, aged care standards can be interpreted differently to suit changed circumstances, as was illustrated by the then Australian Aged Care Quality Agency’s change of tack in the way it carried out assessments prompted by the Oakden debacle. The Accreditation Standards turned out to be a moveable feast, as assessments were done differently and suddenly findings of non-compliance increased dramatically. Essentially, the Accreditation Standards can mean whatever you like them to mean. The same can be said of the Single Aged Care Quality Framework.

Single Aged Care Quality Framework

  1. The Single Aged Care Quality Framework consists of eight standards, which are structured as (1) a Consumer outcome, (2) an Organisation Statement and (3) Requirements. The Requirements are the equivalent of the Expected outcomes under the Accreditation Standards and Home Care Common Standards.
  2. Standard 1: Consumer dignity, autonomy and choice, Standard 2: Ongoing assessment and planning, and Standard 4: Delivering lifestyle services and supports are prime examples of standards that cannot be measured uniformly and objectively. The requirements of these standards are vague and in some instances laughable. For example, Requirement 1.6 Each consumer’s personal privacy and confidentiality is respected and upheld is an odd Requirement for a residential aged care industry that routinely accommodates four care recipients in a single, tiny room. It is simply pointless and wasteful of time and resources to assess provider performance against the requirements under Standards 1, 2 and 4, which is not to say that the areas covered by these standards are unimportant. However, any incompetence of aged care providers in the areas covered by Standards 1, 2 and 4 will more than likely extend to areas where performance can be uniformly and objectively measured and those are the areas on which compliance monitoring should focus.
  3. A similar point can be made about Standard 6: Feedback and complaints and Standard 8: Organisational governance. For a complaints and feedback mechanism and for organisational governance to work well, an organisation must be committed to them. These things will never work well just because, periodically, an assessor from the Aged Care Quality and Safety Commission inspects the service’s paperwork related to complaints and to governance. A service with inadequate feedback and complaints practices and inadequate governance will inevitably trip up in areas where performance can be uniformly and objectively measured.
  4. What would be helpful in the area of feedback and complaints is an Official Visitors scheme. Under such a scheme, which is supported by the Australian Law Reform Commission, Official Visitors would have the authority to enter a residential aged care facility unannounced and to speak with clients and staff confidentially in order to identify any issues for possible referral.
  5. The areas where performance can be uniformly and objectively measured are direct care, service environment and staffing, covered by Standard 3: Delivering personal care and/or clinical care, Standard 5: Service environment and Standard 7: Human resources. Unfortunately, the Single Quality Framework is as vague on what is required in these areas as the Accreditation Standards.
  6. For effective performance measurement in personal and clinical care, there is a need to be very specific about what is required. This specificity should take the form of a detailed protocol for each category of personal and clinical care, referencing where necessary external care protocols. However, Standard 3 merely provides a high level list of what is included in personal and clinical care in aged care settings. For example, the Standard does not refer to oral health, which is neglected in the vast majority of residential aged care facilities and which neglect is the cause of much unnecessary illness and suffering and many premature deaths.
  7. There is widespread concern among nursing and other health professionals about the industry’s performance against Expected outcomes 2.7 (Medication management) and 2.15 (Oral and dental care). While medications should be administered either by a Nurse Practitioner or Registered Nurse, the use of dose administration aids such as Webster and blister packs means that effectively medications are administered to residents by Personal Care Workers and Assistants in Nursing. A 2008 study of the packaging of dose administration aids in 42 NSW nursing homes found packaging incidents in 34 of the facilities at rates between 1% and 54%[7]. In addition, Personal Care Assistants and Assistants in Nursing are not trained to identify these sorts of errors, nor are they trained to know how particular medications interact. Personal Care Assistants and Assistants in Nursing do not have the clinical expertise required to assess a person’s condition in order to determine whether or not it is safe to administer all prescribed medications. If there is no Registered Nurse or Nurse Practitioner administering and monitoring the effect of a medication, there is a risk that an adverse reaction to a drug will not be identified by other care staff. For example, the incorrect administration of insulin or insulin-related medication in a diabetic resident can very quickly become a medical emergency requiring immediate intervention to ensure survival. Another example is the supervision of administration of Schedule 4 and Schedule 8 drugs, which should be the same as in public hospitals.
  8. Standard 3 could also have mandated the use of personal care and clinical care indicators. The National Aged Care Quality Indicators Program currently runs as a voluntary program with just three indicators (pressure injuries, use of physical restraint, unplanned weight loss). These indicators can serve to inform care benchmarks and are used elsewhere in the developed world. Other indicators used overseas include: nutrition, delirium, incontinence, falls, understanding behaviour of people with dementia.
  9. Standard 5: Service environment could have set requirements for residential aged care facilities to be configured according to universal design principles, but instead mentions a number of environmental features and requires them to be adequate without being specific. Standard 5 is also silent about the design and configuration of rooms and how much personal space at a minimum care recipients are entitled to.
  10. Standard 7: Human resources is without doubt the most important standard in residential aged care. A provider’s ability to deliver good personal and clinical care is mainly dependent on adequate staffing both in terms of the number of staff and the qualifications of staff. It is also possible to estimate with accuracy the number and nature of care hours needed to deliver adequate care to a given mix of care recipients at a given service location. However, aged care providers and successive Australian Governments have rejected the idea of not only mandatory staff-to-resident ratios but also the idea of a benchmark. The adequacy of staffing arrangements at residential aged care facilities would be simple to assess if either of these approaches had been adopted. The reason for this reluctance is budgetary. Essentially, the Government keeps aged care expenditure to a minimum while allowing providers to cut corners on staffing to reduce their expenditure.
  11. It is another example of section 2.1 of the Aged Care Act 1997 at work. In this instance, supply is restricted for people needing aged care who are in the aged care system.
  12. Over the years, CPSA has heard many reports of the immense pressure staff face to deliver care within predetermined time frames and according to strictly regimented processes, which limit the capacity of staff to provide care in accordance with client wishes and needs.
  13. Standard 7: Human Resources is not different (except in verbosity) from expected outcome 1.6 of the Accreditation Standards, which covers staffing. The guidance provided through the Results and Processes Guide is for assessors to consider ‘processes’ only in judging whether a facility meets the standard. The Guide suggests to assessors that they go by what the facility tells them are (a) adequate staffing levels and (b) whether these self-identified levels are adequately covered.
  14. This approach to establishing whether a facility meets staffing requirements or not is inconsistent with the approach the Department of Health takes to determining the level of fees payable to facilities under the Aged Care Funding Instrument (ACFI). ACFI is specific about how much is paid to facilities to meet the individual care needs of individual care recipients. Given that the largest cost component of meeting those care needs is wages for care workers, it is not only surprising that the Guide does not link expected outcome 1.6 to ACFI fees, but also that the Department of Health is able to set ACFI fees at all without, apparently, having a standardised calculation of staffing costs involved in the care delivery for which it determines the fees.
  15. Leaving it up to individual facilities to determine what constitutes appropriate staffing levels and what constitutes an appropriate staff qualification mix, has had the predictable consequence that qualified-nurse staffing levels have declined. The deskilling of the aged care workforce has reached alarming proportions. The National Aged Care Workforce Census and Survey (NACWCS) first conducted in 2003 showed that Registered Nurses made up 21% of the workforce, Enrolled Nurses 13%, Personal Care Assistants 58.5% and Allied Health Professionals 7.4%.
  16. In 2017, RNs made up just 15% of the residential direct aged care workforce, Enrolled Nurses 10% and Allied Health Professionals 4.6%, while PCAs grew to 70% of the workforce[8]. While the majority of Personal Care Attendants do hold a post-school level qualification[9], their job is to provide basic personal care and support. RNs as well as ENs practicing within the scope of their training are charged with providing specialised clinical and medical care to aged care recipients. The decline in RN numbers is even more concerning given that the majority of these RNs now spend less than one third of their time providing direct care[10].
  17. At the same time as the residential aged care workforce underwent significant deskilling, the proportion of care recipients with high care needs increased significantly. In 2004-05, 62.9% of people in residential care were classified as having high care needs[11] and in 2016 this had increased to 92% of residents[12]. Obviously, providing quality care for people with complex needs takes more time and a broader range of skills rather than less.
  18. Deskilling in residential aged care staffing mix has had serious consequences. A recent study estimated that there had been a 400% increase in premature deaths among nursing home residents since 2000[13]. The Department of Health has noted research putting the prevalence of pressure sores among aged care residents at between 26% and 42%[14].
  19. In order to address the widespread issues with staffing, particularly in residential aged care, CPSA supports the introduction of mandatory minimum staffing ratios. These ratios must be directly linked to the acuity and care needs of clients as the main purpose of introducing ratios is to ensure that clients receive the care that they need. An example of how ratios are regulated in practice in 150 or so residential aged care facilities operated by the Victorian Government can be found in the Safe Patient Act (Nurse To Patient And Midwife To Patient Ratios) Act 2015. CPSA is not suggesting that the Victorian approach should necessarily be exactly replicated throughout the residential aged care system. However, the Victorian example demonstrates that mandatory staffing ratios in residential aged care can be imposed without the sky falling in.
  20. As the residential aged care industry derives the vast majority of the revenue it uses to pay direct care staff from government subsidies under the Aged Care Funding Instrument (ACFI) and as these ACFI subsidies are calculated with staffing costs in mind, it is reasonable that the community expects the staffing levels these ACFI subsidies facilitate to be identified and published.
  21. It is also necessary to consider staffing levels in home care, especially where medication management and wound care are concerned.
  22. A subsidiary – but critical – outcome of introducing staffing ratios would be an increase in staff satisfaction and overall improvement in the stability of the workforce as staff would be supported to provide care of a high quality and this is a key aspect of job satisfaction.
  23. CPSA regards the Single Aged Care Quality Framework as a sad piece of window-dressing developed between the aged care regulator and the aged care industry, suggestive of a fresh new approach but in reality not different from the inadequate standards regimes it is set to replace.

Accreditation in residential aged care

  1. Accreditation in residential aged care currently covers the accommodation and care functions of a residential aged care facility. The fact that the entity who owns the physical residential aged care facility is necessarily the entity carrying out the care function in it lends great leverage to the aged care provider over regulators and care recipients.
  2. For example, where a residential aged care provider delivers poor care to the point at which revoking their accreditation would be the reasonable compliance response, that response would mean closing down the facility, forcing residents to find a new residential aged care place. Obviously, with the prospect of resident displacement as a result of revocation of accreditation, revocation is likely to only occur in extreme cases, because of the trauma it would cause to residents, particularly if the facility was located in a regional or remote area with few or no alternative facilities to absorb displaced residents. In such areas even a lesser penalty (e.g. the facility not being able to accept new residents for six months) punishes innocent residents and prospective residents along with the guilty provider.
  3. If accreditation was split between accommodation and care functions, i.e separate accreditation for the physical infrastructure and separate accreditation for care provided, the facility could be operated by two distinct entities, one operating the physical infrastructure, the other providing care. The decision to take compliance action in respect of aged care safety and quality would be easier, because the revocation would be for the care accreditation only and a new provider could be introduced to the facility without the need for closure or reducing the overall amount of care fees subsidies paid. Residents would not be punished, only the provider would be punished. Also, the effect of split accreditation is likely to be that it gives providers an incentive to provide the best care they can, because it is now so much easier to lose the care-part of their business due to bad performance.
  4. Another benefit of split accreditation is that it will facilitate Consumer Directed Care (CDC) in residential aged care. CDC in residential aged care is usually understood as residents having the right and ability to move to another facility. Under split accreditation, a residents’ committee could decide that they wanted a new care provider to enter the facility, meaning that the residents stay put and the care provider leaves. This is what CDC allows Home Care Package recipients to do: choose and change their care provider.

Aged care reforms under way now

  1. The Aged Care Sector Committee is the Government’s principal reform-advisory interface with the aged care system. The Committee uses the Aged Care Roadmap as its reform guide. While many of the objectives contained in the Roadmap are laudable, the Roadmap is fundamentally at odds with the objectives of the Aged Care Act 1997 where the Roadmap sets as an objective achieving “a single market-based aged care and support system that is consumer-driven and based on assessed need”. Obviously, the aged care market cannot be consumer-driven where supply is always kept at a level of under-supply.
  2. Also, little consideration seems to have been given to the fact that, as the power of providers grows as a result of consolidation, a replication of what happened in the general healthcare sector with private health insurance will happen in the aged care sector, with skyrocketing costs to consumers and with a low-quality, low-availability safety net for those of limited or no means.
  3. It is likely that the composition of the Aged Care Sector Committee has contributed significantly to the Roadmap painting a picture of an aged care sector, which is not in crisis, but doing quite well under the circumstances, subject to reforms in order to move with the times. Of the fifteen Committee members no less than eight are aged care providers or represent aged care providers, including the provider-dominated National Aged Care Alliance (NACA), which actually represents the other seven aged care providers and representative organisations as well as three of the four consumer organisations. The Alliance also represents the only union which is a member of the Aged Care Sector Committee. The three provider members are also represented by one of the representative provider organisations. In short, providers dominate the Committee numerically in an almost comical way. The Committee is clearly compromised and not in a position to fairly guide Government aged care policy decision-making.
  4. CPSA supports the recommendations of the Report into the Inquiry into Quality of Care in Residential Aged Care Facilities by the House of Representatives Standing Committee on Health, Aged Care and Sport, with the exception of the second part of recommendation 4, which recommends monitoring of staffing levels and quality outcomes. This is more or less current, ineffective practice. CPSA notes and welcomes the support the Standing Committee gave for the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018.[15]
  5. Staffing is also the issue of concern CPSA has with the Aged Care Workforce Strategy. The Taskforce writing the Strategy was, like the Aged Care Sector Committee, dominated by aged care providers. Consumers were largely excluded from the Taskforce, while unions were actually excluded from the Taskforce. The Strategy dismisses the notion of mandatory staffing ratios, Subsequently, the Strategy’s author, Prof Pollaers, recanted on that dismissal and has gone on the record supporting mandatory staffing ratios, insisting they be imposed urgently.[16]
  6. CPSA supports the recommendations of the Carnell – Paterson Report of the Review of National Aged Care Quality Regulatory Processes. However, CPSA notes that the review specifically excludes staffing requirements and defers to the Aged Care Workforce Strategy, which was being prepared at the time of the review, as the right vehicle to make recommendations in this regard. As noted, the Strategy’s author, Prof Pollaers, changed his view on staffing. In addition, the Aged Care Workforce Industry Council, which is to implement the Strategy and which was announced by the Minister responsible for aged care on 17 January 2019[17], seems[18] to have as its members the three industry peaks only (Aged Care Guild, LASA and ACSA). The work of the Council and its implementation ideas for the Strategy as well as the Strategy itself should be viewed with extreme caution and even suspicion by all those who want aged care safety and quality to improve.
  7. CPSA regards the Legislated Review of Aged Care 2017 by David Tune as a non-reforming review. It is a review that further entrenches the objectives of the Aged Act 1997 as set out in section 2.1 of that Act by recommending all the eligibility-program features of aged care supply should continue (recommendations 2 – 10), rather than that aged care should be provided as an entitlement to those who need it. The Tune review explicitly limits HCP funding levels to what it would cost for care to be delivered in residential aged care (recommendation 7). The Tune review also makes recommendations that would force low-income people into residential aged care by compelling them to pay HCP or CHSP fees they cannot afford (recommendations 12 – 18). In a significant concession to the interests of aged care providers, the review recommends the enablement of huge price increases at the discretion of providers (recommendation 19). Finally (recommendation 38), the Tune review recommends the industry optimises the quality and quantity of its workforce within the constraints set by Government subsidies and regulation of care recipients’ co-contributions, rather than calling for a workforce strategy that ensures the availability of quality staff providing adequate care to all those who need it. It is noted here that Mr Tune chairs the Aged Care Sector Committee responsible for advising the Government on aged care reform.
  8. It is noted that the Aged Care Quality and Safety Commission commenced operations on 1 January 2019. The prime reason for its establishment was to bring under one roof (1) compliance monitoring, (2) sanctioning of non-compliance, (3) initial approval of providers and (4) complaints handling. (2) Sanctioning of non-complaince and (3) initial approval of providers will remain the responsibility of the Department of Health until 31 December 2019, while the Single Aged Care Framework will commence on 1 July 2019. The rationale for this hotch-potch of a timeline is unclear. It seems more logical to synchronise the commencement of all the reform components and to have selected as implementation date 1 January 2020 or a date following the completion of the Royal Commission’s work and the Government’s response to the Royal Commission’s recommendations. It is also noted that the Aged Care Workforce Industry Council was formed on 17 January 2019, the day before the first hearing of the Royal Commission into Aged Care Quality and Safety. There seems to be a determined effort to attempt the implementation of planned aged care reforms before the Royal Commission delivers its final report.

Actions required

  1. The Aged Care Act 1997 should be reviewed and its objectives changed or expanded to ensure people needing aged care receive aged care in a safe manner. This requires aged care to be made available under a consumer-directed entitlement program like the National Disability Insurance Scheme.
  2. The aged care system should be integrated with the disability care system, the general healthcare system and the public oral healthcare system.
  3. Aged care safety should be declared a national priority and prime area of focus of the Aged Care Quality and Safety Commission.
  4. Timely access to appropriate care should be formally adopted as a feature of aged care safety.
  5. HCP funding levels should not be predicated on the cost of residential aged care to Government but on the ability of care recipients to be cared for at home.
  6. The undersupply of HCPs should be immediately remedied by making the HCPs program an entitlement program.
  7. A compliance monitoring program for the Commonwealth Home Support Program should be established urgently.
  8. Assessment of compliance with aged care standards should be based on uniformly applied and objectively measurable standards and indicators. The Single Aged Care Framework in its current form does not facilitate this.
  9. Aged care funding through the Aged Care Funding Instrument should be reviewed and the staffing component of care subsidies identified and published.
  10. Understaffing of residential aged care facilities should be addressed by introducing staff-to-resident ratios based on acuity and need. Residential aged care facilities should publish their staffing arrangements for all shifts on a daily basis. Staff ratios should also be prescribed for home care for individual care activities.
  11. Aged care funding through the Aged Care Funding Instrument should be reviewed and the staffing component of care subsidies identified and published.
  12. In residential aged care, the accommodation function and care functions should be separately accredited to facilitate the removal and replacement of the approved provider of care functions where warranted.
  13. An Official Visitors Scheme for residential aged care should be established.

 

Notes:

[1] Home Care Packages Program, Data Report 1st Quarter 2018-2019, Dept of Health, November 2018.

[2] p42, Report on the Operation of the Aged Act 1997 for 2017-2018, Dept of Health, November 2018.

[3] Report on the Operation of the Aged Care Act 1997, 2015-2016, Dept of Health, November 2016.

[4] Report on the Operation of the Aged Care 1997 for relevant years.

[5] Results and processes guide, Australian Aged Care Quality Agency, October 2014.

[6] Quality Surveyor Handbook, Australian Aged Care Quality Agency, October 2018.

[7] Carruthers, A. Naughton, K. Mallarkey, G. (2008) ‘Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales’ Medical Journal of Australia 188 (5)

[8] Mavromaras, K. et al (2017) ‘2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016’

[9] King et al (2013) ‘The Aged Care Workforce, 2012 – Final Report’. See Tables 3.12 and 5.12.

[10] Table 3.36: Mavromaras, K. et al (2017) ‘2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016’

[11] Commonwealth of Australia (2005) ‘Report on the Operation of the Aged Care Act 1997 – 1 July 2004 to 30 June 2005’ pp.13

[12] Australian Institute of Health and Welfare (2017) ‘People’s care needs in aged care’ GEN Aged Care Data.

[13] Ibrahim, J. et al (2017) ‘Premature deaths of nursing home residents: an epidemiological analysis’ Medical Journal of Australia, 206(10), pp1-5.

[14] Department of Health (2017) ‘Single Aged Care Quality Framework: Draft Aged Care Quality Standards Consultation Paper’ pp.22

[15] Standing Committee on Health, Aged Care and Sport, Advisory Report on the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018, 7 December 2018.

[16] Australia should be a world leader in aged care delivery, media release Australian Nurses and Midwives Federation, 15 December, 2018.

[17] Aged Care Workforce Industry Council, Media release, Hon Ken Wyatt MP, 17 January 2017.

[18] CPSA contacted the office of the Hon Ken Wyatt MP, Minister for Senior Australians and aged care on 29 January 2019 to confirm membership of the Council. No response had been received by 4 pm on 31 January 2019, the deadline for lodgement of this witness statement.

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