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This review was undoubtedly a response by the labour controlled senate to the rather bland self-congratulatory report "Future Ageing" from the government controlled House of Representatives' Standing Committee on Health and Ageing. It gave a voice to those who were unhappy with the aged care system.
It drew attention to the parlous state of nursing in aged care, and the adverse effect this was having on care. This was in spite of 34 reviews addressing the issue over the previous 7 years. Some providers were finding excuses to discriminate against nurses. In addition it emphasises the shortage of doctors and other health care workers in the sector. Geriatricians felt marginalised and discouraged.
The report was very critical about the accreditation process and the agency, quoting a nursing association claim that the process was a farce. The committee questioned the effectiveness of accreditation and made many criticisms of the process, concluding that it was not effective.
The review was also very critical of the complaints mechanism finding multiple deficiencies. It documented the fear of intimidation felt by those who complained. It recommended whistleblower legislation to protect them. This has not happened.
The labour party were in a majority in the senate and this review may well have been a response to the coalition dominated review by the house of representatives Standing Committee on Health and Ageing. It was initiated in June 2004 at a time when the house of representatives review was almost completed (this report was due August 2004). They would have been aware that this would be a feel good document that did not document failures adequately.
What this review does is to address this imbalance. It documents what those who were unhappy about the system - those at the coalface - were telling politicians. It quotes many of them. It is clear from this that there were extensive problems in Australian nursing homes, that they were not being detected. Neither the accreditation system, nor the complaints system were working. The report does not come up with any clear alternatives, and we simply get more of the same. The political cost of proposing real change was probably too great.
The brief for the review included the adequacy of current proposals, the performance of the accreditation agency and the complaints system, the problem of young people with disabilities in nursing homes, Home and Community Care programs and the effectiveness of transition programs between sectors.
In the 9 months before reporting this committee receives 253 submissions, conducted 9 hearings and visited several facilities accomplishing as much as the standing committee had done in nearly 3 years. It may be that many with experience felt that the coalition standing committee would downplay their concerns, and responded instead to this inquiry.
The issues of particular interest to me at this time are staffing, accreditation and complaints.
The first issues addressed were the serious problems in staffing. These had persisted in spite of numerous previous inquiries, including that done by this same senate committee in 2002. The responses had been hopelessly inadequate. The report documented how staffing levels and deskilling had become steadily worse. The deficiencies by then extended to multiple other groups working in nursing homes.
Issues surrounding workforce shortages and training in nursing, including the aged care sector, have been debated and reviewed for some time: there have been 34 reviews of nursing in seven years. Indeed, in June 2002 this Committee tabled its report on its inquiry into nursing. In the report the Committee noted the acute shortage of nurses in the aged care sector.
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Evidence received during this inquiry suggests that there has been little improvement to the situation since 2002 with concerns being raised not only about the shortage of aged care nurses but also general practitioners with older persons' health expertise, geriatricians, psycho-geriatricians and allied health professionals. (Page 3)
The ANF (Victoria) commented that in Victoria the skills mix of Registered Nurses (RNs) to residents had fallen from an average of 1 RN to 30 residents across all shifts in 1997 to 1 RN to 60 residents during the day, out to 1 RN to 90 or 120 at the evening and night shift. (Page 6)
Submissions by unions with members working in the aged care sector pointed to evidence from their members and union surveys that show that nurses and other health care workers do not believe that they are able to spend enough time with residents to deliver the care that residents require; (Page 48)
In its conclusion on aged care workforce issues, the Committee can but reiterate what has been said many times before: that the shortage of nurses is real, is increasing and is impacting on the quality of care being delivered in all health sectors but more particularly in the aged care sector. (Page 28)
The report documented that in spite of the shortages there were concerns about discrimination against some nurses and discouraging others. A market critic would ask whether this was a pretext to limit staff and so keep costs down. The committee did not. Staffing comprises two thirds of costs and the single largest brake on profitability. It is naive to suggest that profit focused entities will make concerted efforts to increase staffing. They will find reason's why they can't.
Dr K Price of the Centre for Research into Sustainable Health Care also noted that employers are reticent to employ older workers because of their age. Research had indicated that aged care employers considered that older workers were at risk of injury and were using occupational health and safety laws not to employ older workers.19 (Page 6)
Dr Price (Centre for Research into Sustainable Health Care) also commented:
...we limit the number of RNs, we limit the number of ENs and we put in care workers with only a certificate 3 at the most - and we expect to get a workforce. Why should an RN go into a workforce where he or she knows that they are going to be the only one on for 60 residents? Why should somebody? We have to stop it at some point. There should be many more. There is a one to five ratio in acute care: why isn't there that ratio in aged residential care? (Page 7)
Of particular concern was the lack regular support and supervision for many workers. Many organisations provide only limited support to workers to undertake training - in some cases all training costs, including time, are borne by the worker. (Page 8)
Particularly worrying was that geriatricians, the one profession able to monitor and control abuses felt that they were being marginalised and discouraged.
However, 'government health programs such as the existing Medical Benefits Schedule (MBS) structure and the MedicarePlus initiatives economically marginalise the geriatric medical workforce and restrict the provision of private hospital, community and religious specialist aged care' - - - - - - The Australian Society of Geriatric Medicine also commented on the lack of geriatricians and other specialists working in aged care facilities. (page 11)
It is clear that while the providers and the agency were generally positive about the accreditation process, those who made submissions to this review held very different opinions and led the committee to a different assessment. These submissions come from the coal face, and reiterate what has been said but ignored on multiple occasions.
The issues raised include a failure of the agency to detect problems, the absence of any systematic data to link accreditation to quality of care, a lack of consistency, and unacceptable levels of subjectivity. The imprecise and generalised nature of the standards made it difficult to measure outcomes. As a consequence many considered the process to be gamed by providers and to be a farce.
A selection of quotes are representative.
The Health Services Union (HSU) noted argued that the Agency 'is failing in its duty to ensure that an adequate standard of care and safety is provided to elderly residents in aged care facilities'. The Australian Nursing Federation (ANF) also noted that many of its members have raised issues about inadequate standards of care and inadequate staffing levels in aged care facilities. (Page 34)
COTA National Seniors expressed concerns as to the extent to which accreditation has contributed to high quality care for residents and real options about lifestyle for residents. The Combined Pensioners & Superannuates Association of NSW (CPSA) stated that the performance of the agency 'leaves much to be desired'. The Association argued that part of the problem is that the Agency is not set up to directly control aged care facilities. (Page 34)
Evidence indicates that there is little systematic data that demonstrates how accreditation has impacted on quality of care. One submission noted that the Agency has 'not produced any material which would provide the sector or the community with any level of assurance that the overall intention of accreditation in improving service quality has been achieved'. (Page 34)
The Committee also believes that a significant reason for the lack of consistency relates to interpretation of the Accreditation Standards which are expressed in very generalised terms and therefore open to markedly different interpretations. (Page 38)
Some submissions argued that accreditation processes encouraged some homes to employ additional staff and generally 'tidy up' the facility prior to the arrival of assessors which created a false impression of the true nature of the facility and the services provided. (Page 38)
The NSW Nurses' Association also noted that members routinely reported that 'the accreditation process is a farce as everything is set up for the day and then disappears'. (Page 38)
The Committee is concerned, however, that the evidence received suggests that some homes may engage in the practices described above. It notes that complaints of this nature come from staff 'on the ground' and therefore people in a position to know the day-to-day management practices of homes. (Page 39)
It was claimed in evidence that the Standards are too imprecise and far too generalised to effectively measure care outcomes - - - - - . The Aged Care Lobby Group also noted that while the Accreditation Standards assess standards of care to some extent - 'it needs some refinement. It is too subjective. It relies on what is written by the provider and statements by relatives and residents.(Page 47)
A study by Professor Gray also noted that:
To the extent that the Agency does not assess actual care delivered, but infers it from the information provided by residents, staff, families and relevant documentation, its capacity to provide objective information around care outcomes is limited. (Page 47)
The review, like others before it urged greater involvement of the community and the provision of better information to "consumers".
Evidence indicated the need for the Agency to involve residents and their families to a greater extent than currently occurs in the accreditation process and also in promoting informed consumer choice. (Page 29)
In their conclusion the review concluded that the accreditation process was not effective.
Evidence indicates that in a range of areas from medication management to access to medical services there are significant problems in the provision of services to residents in aged care facilities. (Page 58)
It was suggested in evidence that the Accreditation Standards are failing to measure areas where care is clearly deficient. The Committee believes that the Accreditation Standards are too generalised to effectively measure care outcomes. The wording of the Standards necessarily lead to varying levels of service being provided in homes because the Standards are open to widely different interpretations by proprietors and assessors. The Committee believes that the Accreditation Standards need to be defined more precisely so that standards of care in aged facilities can be delivered - and measured - in a consistent manner across all aged care facilities. (Page 58)
The evidence once again showed that the complaints system was not working for residents nor for their families but was working for nursing homes.
Submissions argued that the complaints mechanisms often do not work in the interests of consumers, and the mechanisms are unclear, unnecessarily complex and in some cases complaints are actively discouraged. (Page 60)
The very strong message that NCOSS gets from the Aged Care Alliance consumer groups is that the complaints mechanism is not accessible to people and not responsive (Page 61)
The Aged Care Lobby Group argued that family members have given up complaining to the CRS because the overall impression is that 'their complaints are trivialised or are made by an over-fussy, neurotic or guilt-ridden family member'. (Page 61)
Evidence suggests that the number of complaints would be considerably higher if the CRS did not use such strict criteria for accepting complaints - in effect the CRS 'culls' the number of potential complaints. This also has the effect of discouraging many potential complainants from making complaints (Page 62)
The committee was concerned that there was a fear of intimidation among residents which prevented them from complaining and that this was happening. They concluded that this was happening across many states
Evidence was presented during the inquiry detailing the fear of, or instances of, actual retribution and intimidation of residents and/or their families if residents or their families complained about conditions in homes or the quality of care. - - - - - Information indicated that retribution or threats could occur in a number of situations, for example, staff against residents, management against residents or management against staff. (Page 65)
The conclusions about the complaints scheme.
Evidence to the inquiry suggests that there are deficiencies with the operation of the Complaints Resolution Scheme. Concerns were expressed that the Scheme is not accessible nor sufficiently responsive to the needs of consumers, and the complaints mechanisms are unclear, unnecessarily complex and in some cases complaints are actively discouraged. The relatively high non-acceptance of complaints by the Scheme would indicate that there are grounds for concern. (Page 64)
The Committee also considers that whistleblower legislation is required for those people wishing to disclose inadequate standards of care in aged care facilities. (Page 64)
Evidence to the Committee pointed to instances of retribution and intimidation of residents in aged care facilities and their families across many States. The Committee found this evidence particularly disturbing and reprehensible as these practices prey on particularly vulnerable people and cause obvious concern to the families of residents some of whom may themselves be victims of intimidation. (Page 68)
The review looked critically at the difficulties and enormous problems when young people found themselves in nursing homes - how destructive this was for them. It concluded that this was unacceptable and that the government should
It looked at the deficiencies in the funding for residents with special needs, at community care programs which it strongly supported and at the need to properly coordinate transitional care between community, hospital and nursing homes.
I am not going to explore these other issues in the report further.
The Hon Julie Bishop MP Minister for Ageing promptly issued a media release "SENATE INQUIRY SHOWS LABOR STILL A POLICY FREE ZONE" attacking the report.
She totally ignored the many complaints about the system. She evaded the issues by attacking labor as a "policy free zone" and made extensive claims about what the government had already done. She claimed that "the Australian Government has already either addressed, or is implementing many of the recommendations outlined in the Senate inquiry report".
It was not until September 2007 that the government released a formal response.
The government indicated that, except for 4 items with which they disagreed, they had or were addressing all of the issues in one way or another. They did not address those issues where it was government policy to use market forces to drive the processes. This included the issue of parity of aged care nurses. This the nurses had to negotiate with providers.
The Government does not agree with this recommendation. The aim of the conditional adjustment payment (CAP) is not 'to restore wage parity'. Wages and other employment conditions are matters between employees and employers subject to relevant legislation including the Workplace Relations Act 1996, as amended by the Workplace Relations (Work Choices) Act 2005.
The response did not specifically address any of the deficiencies identified by the senate report.
The full report can be found at
The government's formal response can be found at
http://www.aph.gov.au/senate/committee/clac_ctte/completed_inquiries/2004-07/aged_care04/
Click Here to go back to the main report page
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