May 24, 2019

Staff ratios: can Australia afford them?

Staff ratios are one of those issues that divide the aged care industry.

There are those who say mandated staff ratios are essential to delivering the standard of care we expect for our senior citizens, and then there are others who say mandated staff ratios will do little to improve quality of care, and may even mean some operators, especially those offering precious services in remote and regional areas, will have to close.

In an ideal world, aged care facilities would be staffed by an army of experienced and qualified staff. But it that realistic? If there is no flexibility, regardless of the circumstances, could mandated staff ratios have unfortunate unintended consequences?

Here at HelloCare, we wanted to get to the bottom of the issue, so we’ve asked the key voices in the industry about their views.

Fixed staff ratios a “recipe for disaster” for small rural and remote providers: Ken Wyatt

“Our Government is 100 per cent behind Australia’s dedicated aged care workers because we know a proud and professional workforce is the foundation for quality care,” Ken Wyatt MP said in a statement to HelloCare.

“No serious body that has looked at the issue of staff ratios has supported fixed inflexible ratios. This includes the Aged Care Workforce Strategy Taskforce, the Productivity Commission, the Senate Community Affairs Reference Committee and the Legislated Review of Aged Care.

“Remember that South Australia’s infamous Oakden facility had extremely high numbers of nurses yet the treatment of residents was despicable.

“Fixed and inflexible ratios almost certainly will not help aged care quality.

“This is a recipe for disaster in the bush, where inflexible ratios would effectively force the closure of aged care homes in regional, rural and remote Australia.

“They risk a massive impact on small rural and remote providers, who would be required to meet staff ratios set by reference to specialist large-scale city providers.

“Aged care providers are already required to ensure they have adequate numbers of staff to meet residents’ needs – the new Aged Care Quality and Safety Commission undertakes unannounced audits to ensure aged care facilities comply.

“We know this works without the need to mandate fixed and inflexible ratios for every provider regardless of their residents’ needs.

“In 2017-18, 12 aged care services across Australia had their accreditation revoked, including for inadequate provision of staff.”

Government must mandate minimum staffing levels: ANMF

Since early 2018, the Australian Nursing and Midwifery Federation has been campaigning for mandated staffing ratios in aged care.

The  ANMF’s recent Aged Care survey found that 89 per cent of the aged care staff surveyed said there were inadequate staffing in aged care. Three-quarters of the survey’s participants noted that staff ratios were inadequate,

Ahead of the federal election, Annei Butler, Federal Secretary of the ANMF said, “We cannot wait another 18 months until the conclusion of the Royal Commission – the pain and the suffering of the elderly in our care must be a… priority and a commitment to mandate minimum staffing levels is where they must start.”

(HelloCare reached out for a comment from the ANMF, but had not received a response at the time of publishing.)

More funding is needed to train quality staff: Sean Rooney, CEO LASA

Sean Rooney, CEO Leading Age Services Australia, told HelloCare, “The sector needs to work towards ensuring providers have the right number of staff, with the right mix of skills, to meet the different needs of every resident or client in their care. That must apply to every different type of aged care setting.

“Essential to this is appropriate resourcing of the sector that reflects the true costs of care and provides the capacity to train and retain quality staff. This means ensuring adequate industry funding and appropriate employee remuneration.

“The work of the Research Centre recently announced by the Federal Government will be well-placed to address priorities such as identifying optimal models of care that are linked to the aged care standards and determine the workforce skill mix and training such models require.”

We need more registered nurses in aged care: Sarah Russell, aged care researcher, founder Aged Care Matters

Sarah Russell, founder of Aged Care Matters, told HelloCare, “We must start the process of improving staffing levels and training in aged care homes. This requires all key stakeholders – aged care advocates, residents, relatives, staff, government and providers – having a robust conversation that is supported by evidence.

“Recent inquiries have made recommendations. Let’s start by implementing Recommendation 8 of the Future of Australia’s aged care sector workforce inquiry:

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

“My articles in The Conversation (2016) ‘Here’s why we need nurse-resident ratios in aged care homes’ and ABC online (2018) ‘Better aged-care begins with more registered nurses in homes’ show that I have consistently supported legislation to mandate at least one registered nurse on site (i.e. not merely ‘on roster’) in every aged care home 24 hours per day.

“My recent research – in which I asked 396 people who work in an aged care home ‘Does the aged care home where you work have a registered nurse on site each shift?’ – indicated that 25 per cent of aged care homes do not have a registered nurse on site 24 hours per day.

“I also support the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 that mandates the publication of staff-to-resident ratios by job description on the My Aged Care website. This will help the public to choose a good aged care home and avoid the bad aged care homes.

“I support evidence-based policies. Evidence shows that when registered nurses are on site, residents have better health outcomes, a higher quality of life and fewer hospital admissions.

“Unfortunately, as demonstrated in my article in HelloCare (2018) ‘To ratio or not to ratio: that is the question’, many key stakeholders base their views on opinions not evidence.

“Mandating ratios of staff (i.e. registered nurses, PCAs, activity staff) will have a minimal impact on good aged care homes. A good aged care homes employs significantly more and better-qualified direct care and trained activities staff than a bad aged care home.

“Mandating staff ratios will have a negative impact on bad aged care homes because these providers will be forced to employ more staff. Hopefully it will encourage those providers who prioritise profits over care to leave the sector.”

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  1. This comment was sent to us by Stewart Johnson, whose mother Helen experienced abuse at the notorious Oakden nursing home in South Australia.
    Interesting discussion that has engulfed enraged and encouraged all sorts of views and opinions.
    Staff ratios is a complex reform.
    Absolutely reform is needed in this area but again it is all encompassing if we are to truly find a new best practice.
    Human Resources as a whole, the recruitment, training, career development, renumeration as well as adequate coverage are all as important individual and collectively.
    However we must reflect reality.
    The Crux of the issue i believe is that the model of Residential Aged Care is fundamentally flawed.
    Many references are made to the fact oakden had staff ratios. Indeed they did because it was classified as an older persons mental health facility due to the fact it’s 78 residents were all high care /level dementia. Their “profile” showed they had been through traditional “mainstream” RACF and deemed to high level due to the debilitating level of Dementia etc.
    Had oakden had the caring, compassionate, innovative culture to match the outstanding ratios it would have been best practice but we all know the reality.
    My point is, sadly, dementia is by far the most prevalent across a much wider population, it’s prevalence is affecting people earlier and to a severity not seen previously.
    The figures are astounding.
    Equally though the provision and extensive planning of and subsequent availability of acute specialist facilities such as a best practice “oakden” have not even been on the horizon.
    As such our traditional RACF have been the only option, further rewarding the unscrupulous providers who via the flawed funding mechanism have been able to secure the best return on human investment ( as they probably call it on their spreadsheet) without any regulations in place for care ratios as should be the case in the delivery of adequate care for the level of dementia present.
    So I firmly believe that RACF need to be split in two.
    For the specialist facilities who wish to specialise in the best practice world renowned delivery of adequate care needed for extreme category 6/7 Dementia and or other extreme cognitive/disabled they would be mandated to have in place optimum highly skilled staff with legislated staff/patient ratios as us the case in mental health facilities already but with the essential funding available to fulfil this delivery of care.
    The traditional RACF environment would then be a hive of activities, individual empowerment and community engagement with a suitable level of care, again the appropriate staff levels and allied health involvement all targeting a health and well being outcome and truly rid the stigma of a care facility being the final step before pending death.
    I truly believe this is the only way to rid us of the one size fits all corporate care home that’s focussed purely on maximising income and minimising everything else.

  2. Profits over care? “Really is that what you want to think?

    The simple fact of the matter is that the residential care industry has had funding slashed by the liberal government. That money has for the most part been poorly spent on trying to initiate a home care industry that already has proved itself unreliable, expensive and open to massive rorts!

    As a residential provider of a single facility (recently voted as in the top three in Canberra) it is essential that any business makes a profit. We have commitments to the bank, staff and common sense. Up until recently our industry has been able to deliver safe reliable service and make a small profit. Why would or should anyone object to that is beyond me. I don’t see any other business accepting to lose money.. and how does the morallly outraged expect industry growth, renovation etc?

    I read to the point of nausea the comments about the big facilities and their tax practices, but I don’t see anyone being charged because they have the same right as any other business to minimise their tax.. legally. So let’s at least move on about that.

    The above comment of “human investment” is contemptable and splitting facilities into two types is not new. We had exactly that up until about twenty years ago when the government closed down asylums and wasn’t that a success? Ten years after closing these places 70% of the previous residents had where about unknown and since then there has been virtually no suitable place for these poor buggers to go, Well done.

    1. Dear Anton,

      I am aware there are many good private aged care homes. My parents lived in one – it was extremely well staffed – not only direct care staff (RNs, ENs, PCAs) but also several well trained activity staff, a qualified chef (and support staff in kitchen) and a very competent maintenance person. Of course the owner made a profit – it was his business. My point is mandating ratios would not affect his business because his aged care home is very well staffed. This is the same for other aged care homes that deliver high standards of care.

      However, the heart breaking stories we are hearing at the RC provide evidence that there are also private aged care homes that do not provide high standards of care. From what I have heard over past 3 years (via my Aged Care Matters Advocacy Facebook page) is that these aged care homes are very poorly staffed. Let’s take Bupa aged care homes as an example. It seems to me that Bupa prioritises provits over care. There are other examples I could give.

      My aim (as an aged care researcher) is to encourage transparency – so that I can use data (evidence – e.g quality indicators, rosters) to distinguish the good aged care homes (both private, not-for-profit and government owned) from the bad aged care homes. Ideally, all unscrupulous operators (those who prioritise profits over care) should leave sector (both residential and in-home care).

      FYI – The ABC has fact checked your claim “the residential care industry has had funding slashed by the liberal government”.

      1. Hi Sarah,
        I checked the data sheet you quoted and regrettably you have fallen into the trap devised by the liberal government.
        Funding over those periods to “aged care” has increased overall. Unfortunately what the data doesn’t tell us is that “aged care” has been redefined. Where it previously meant residential care it now includes Home care and that is where the funding has increased. This has been at the real expense of residential facilities and your Data confirms the numbers.
        Beside the cuts to ACFI (tool to determine funding) the CPI has been blocked, payroll tax subsidy was dropped and the dementia supplement was axed etc.

        The government has deliberately confused the issue by lumping different care scenarios together where they have “taken from Peter to pay Paul” and homes are struggling while massive waste and rorting is commonly reported in home care. It is at least good to know that you are looking at the issues.

  3. Some providers only wants profit and don’t want to provide more staffing even 2 or more staff required to care for the specific area and the staff on floor end up looking after 8-10 residents which is practically impossible and reduced quality of care. I think which is not fair for the residents who pays the price and decline in nutrition, social, emotional wellbeing.

  4. Lets face it there is no excuse for not having clear evaluable guidelines based on properly collected publicly assessable data and acuity and setting minimum safe levels. There can be no excuse for not making them publicly available. Anything else is self-serving nonsense. Others in more complex situations have done that successfully. In 1985 this was studied and guidelines were developed in Victoria but the results were ignored by a government bent on keeping costs down.

    That we cannot afford it is not an excuse for not knowing and specifying what should be there for safe care. If we need to ration then that should be open and honest. We should be able to see how it is done and how close to safe levels we can get. Care of any sort is a bottomless pit and has always been rationed to a greater but preferably lesser extent.

    Surely the real difficulty is the system that we have. Is it possible for the sort of free market competition and efficiency driven, and private equity (bank) owned market to ration for the benefit of the residents rather than for profit? Is it possible to address this and discussing it with our communities when we are flooded with idealised images and the sort of false rhetoric, marketing and branding with which we being flooded?

    Is it possible for this market to work with the communities where they operate and come up with the best possible outcome for the vulnerable people who need care with the resources available? After all as a community and a society we are all ultimately responsible for our less fortunate fellows and anyone who does that is accountable to us. The altruistic values on which care depends are community values and not market values.

    There has always been a market of sorts in all types of care. It facilitates transactions with the community and its members and in itself a market is not a problem. It can and has embraced community values. But the one size fits all ‘neoliberal’ model that was thrust on us in 1997 has not worked here or in any other country and the reason is pretty obvious.

    Neoliberalism was founded on the belief that mankind was essentially selfish and this was a good thing. It did not understand empathy or that we were all a part of a web of relationships – a society. It made no allowance for vulnerability. The philosopher that popularised it in the USA described altruism as a disease imposed by society. She and other leaders in the sector condemned society and its control over our excesses as socialist and something that destroyed individual freedom. Society became something to be ‘managed’ and controlled.

    Part of our problem must be that we have a system that depends on altruism, a community and not a market attribute. We are providing aged care using a specific sort of market mechanism that was designed to limit and exclude community and its values – values that restrained the excesses of the market and supported cooperative effort.

    Perhaps we should change that by reclaiming the role of citizens and the community in setting and controlling the values in aged care. We could then work together to balance the needs of the elderly with those of the young when using and stretching resources when we can’t afford both. Those who provide care on our behalf are accountable to us and we should put ourselves in a position to ensure that they are.

  5. Mandating ratios may assist in attracting staff into Age Care as currently staff turnover can often be related back to staff feeling pressured, inadequate and over worked. We need a qualified staff mix to be able to provide the daily assistance due to the high acuity of the consumers who stay at home longer and come to us to be cared for with their many complex health needs.


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