Staff Ratios – Royal Commission Research Paper

I have read with interest late last week the very freshly released Royal Commission research paper (1) into aged care staffing requirements, and the shortfall in funding needed to raise the staffing mix and levels to appropriately care for the average residential aged care service consumer.  

The following excerpt from the recommendations paints a picture of what residents, families, advocates, and indeed some providers have been saying for some time – the level of service provision (staffing) in residential aged care in Australia is substandard.  

My conclusion is that because that level of provision is so strongly associated with the operating funding mechanism, the funding mechanism for care is equally substandard:

“more than half (57.6%) of Australian residents receive care in aged care homes that have unacceptable levels of staffing (1 and 2 stars).

To bring staffing levels up to 3 stars would require an increase of 37.3% more staff hours in those facilities. This translates into an additional of 20% in total care staff hours across Australia.

We have not limited our analysis to determining the additional resources required to bring facilities up to an acceptable level. We have also provided an indication of the additional resource requirements that are required to deliver staffing levels consistent with good practice and best practice care.

For all residents to receive at least 4 stars (what we consider good practice) requires an overall increase of 37.2% in total care staffing while 5 stars (best practice) care would require an overall increase of 49.4% in total care staffing.” (2)

As you are probably well aware, I am the CEO of Braemar Presbyterian Care (“Braemar”). To put our services into perspective, since I joined Braemar in March 2017 we have been increasing hours per resident per day to a level that is close to the current national average as recorded by the StewartBrown benchmarking service (3) reporting.  And, as far as is reasonable, we have been improving our subsidy income to match the staffing.  But that recurrent income is not enough.  

According to this research paper, prepared for the Royal Commission into Aged Care Quality and Safety, less than 3 star level of staffing is unacceptable, while a 4 star staffing is good practice, and 5 star staffing is best practice.  Yet 57.6% of residents receive less than 3 star (unacceptable) staffing and only 1.4% receive best practice staffing.

How is this translated into the care of our elders? 

Continue reading “Staff Ratios – Royal Commission Research Paper”

My 2018 Christmas Message

Christmas Time Thoughts

Many years ago, I spent one Christmas time away from family and stayed with friends in the Great Southern area of Western Australia. Their father had died when they were both quite young. 

View this greeting as a video.

As boys, these brothers became the men in the family and over time built up their farming property to be a successful enterprise.  They were both good, honest, hardworking men, who also were faithful in their Christian belief.

I could certainly talk with them about harvest time, how the wheat, barley,and oats grew, why back then one had to wait until a little later in the morning to start up the header and get out and cut into the crop.  But talking about personal things was difficult for them – they were just quiet guys who had some really good things to say, but just didn’t much like speaking it out.

There is this man talked about in the Bible who really had a huge impact about all we believe and practice at Christmas time, but of whom, from Scripture, we never hear a spoken word.  We hear from Mary, the mother of Jesus, in the first chapter of Luke’s Gospel.  Tradition has called Mary’s Song the Magnificat.  We hear from Elizabeth, the mother of John the Baptist, and (eventually) from Zechariah, John’s father.

But we don’t ever read a recorded word that was spoken by Joseph.  Oh,we read of his at least three dream encounters with an angel, or God Himself –first with a message to take Mary as his wife and raise Jesus as his father;the second to flee from Israel and travel to Egypt – an historic refugee journey – and third; to return to Israel because it was now safe to doso.  Given the cultural and societal significance of all of the above,Joseph was a very courageous man.  The strong silent type if you will.  A lowly carpenter, from one of the lowliest places in the whole of Israel, at that time overrun by the Roman Empire, and “ruled” by a king who was a Roman puppet.  Joseph did not have to do this, but he felt so led by God that he could not avoid the challenge set before him.

Just a day or so ago I read this social media post: “Sometimes God will puta Goliath in your life, for you to find the David within you.”  I am sure that Joseph will have wondered something like “You want me to do what exactly?”,or “Why me?”, but he did.  We just don’t ever hear his thoughts and words expressed.

There are some significant challenges in the year ahead for our aged care work.  The looming Goliath is of course the Royal Commission into AgedCare Quality and Safety.  You may already feel quite uneasy about what that is likely to reveal and how we will get through this.  We will – no matter how much we are required to provide, and even to share with the Australian public – we will get through this.

My concern for each of you though is that even if your voice does not godown in any formal recorded historical moment, if you have any concerns about your wellbeing through this next twelve months, speak up.  We want to also care for you.  If you need at any time to share any concern about our behaviour that is both unbecoming, and contrary to our desire to provide a dignified life to our residents, then please share that with us too, so that we all be a “David” and improve how we provide our services.

Folks, I pray and hope that your 2018 Christmas brings you much joy, peace,and blessing, and that you have at least some time to reflect of the enormity of the coming of Jesus into the world – not to destroy the world, but to saveit!God bless you all – and Happy Christmas!

Aged Care Sector Financial Comparators

These days I only read the newspaper on the weekend.  My favourite is still The Weekend Australian.  It often has thought provoking articles, and occasionally some fodder upon which one can reflect from an aged care sector perspective.

The December 8-9, 2018 edition is just one of those occasions.

On page 2, there is an article bemoaning the recent year upon year increase in private health insurance premium rates.  The article reports that ‘Health Minister Greg Hunt … expected to approve an industry average below 3.95 per cent … the lowest since 2001.’ It also includes commentary about the anticipated significantly lower rate increase out to 2022 promised by the current Federal Opposition.   

According to Australian Prudential Regulation Authority (APRA) figures cited by The Weekend Australian, the industry weighted average premium increases approved by the Minister for Health since 2015 are as follows:

2015: ​​6.18{325a31833073d9460f7a78bcb516ce0c388f4161360d4b20624508c43d55a27c}

2016: ​​5.95{325a31833073d9460f7a78bcb516ce0c388f4161360d4b20624508c43d55a27c}

2017​​: 4.84{325a31833073d9460f7a78bcb516ce0c388f4161360d4b20624508c43d55a27c}

2018​​: 3.95{325a31833073d9460f7a78bcb516ce0c388f4161360d4b20624508c43d55a27c}

2019​: Under​ 3.95{325a31833073d9460f7a78bcb516ce0c388f4161360d4b20624508c43d55a27c}

I understand the impact of high levels of private health insurance premiums, that seem reachable by those who for whatever reason determine them to be affordable.  What is more, in contrast to aged care funding, the payment of insurance premiums does not come from the Government purse, but rather from individuals who have determined their affordability.

I find this article useful, if only because for almost the past twenty years I have been monitoring Health Ministers making similar approvals for health insurance premium increases yet at the same time, as the senior Minister over the aged care portfolio, makingstarkly lower indexation for payments for recipients of care or, more indirectly, to the providers of care to aged care recipients.

The comparison of funding increases made to aged care providers through the various indexations against several alternate indicia is shown below:

The chart above clearly shows that whilst aged care funding indexation has indeed kept fairly much in line with CPI, it has failed to keep close to Work Price Index (“WPI”), Average Weekly Earnings (“AWE”), and the greatest gap is between aged care funding and private health insurance premiums.

I will be among the first to say that additional funds are not always the determinant of better quality.  Yet the absence of an equitable funding methodology in residential aged care since 1997, and growing concern about insufficient supply of places in community based aged care since February 2017, seems obvious.  

Inclusive of some $1.7 billion removed from forward funds in 2015 and 2016, there is a clear pattern of diminishing Government expenditure in aged care over the past twenty years to a point where it is highly unlikely that even courageous and good providers of care will be able to sustain their service provision without a sizeable injection of funding.

It has been just three days since the Federal Standing Committee on Health, Aged Care and Sport recommended support for the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018.

I support the recommendation that aged care providers disclose their staffing ratios. However, it would be unreasonable to expect that providers will be able to achieve a reasonable staff ratio without an immediate and substantial injection of funds – albeit with reporting requirements.

Perhaps the Royal Commission can consider this matter in their review processes into the whole aged care sector quality and safety funding and performance?

Nice chatting

Wayne L Belcher

Bibliography

Alex Grove, Residential aged care funding: recent developments Parliament of Australia

House of Representatives Standing Committee on Health Aged Care and Sport, ‘Advisory Report on the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018’ (Commonwealth of Australia, Canberra), December 2018 

Sean Parnell, ‘Rise in health premiums likely lowest in decades’, The Australian (Sydney, NSW), 8 December 2018

Funding Cuts: You Decide!

I gathered these thoughts together the day the Royal Commission into Aged Care Quality and Safety was announced – Sunday 16 September 2018 if my memory serves me well.

This information gathering was in response to the first question of the Prime Minister when making the announcement. The question was around the alleged $1.2 billion cuts to aged care.

Folks, I get it – there have been many cuts from both major sides of our Australian Government over a number of years. And there has been continuing growth in aged care funding based on population related indices etc. But what is galling around these discussions is that the major political parties and the bureaucrats seem unwilling to give simple, transparent responses to questions about these matters.

The recent Federal Senate Community Affairs Committee Hansard from 24 October 2018 make for mind numbing obfuscation around this very issue, with Opposition asking relevant questions, and Government, and Officers, all putting in their opinions, without any direct answer to what should be a simple question. This of course happens regularly at such Committees and is not confined to Aged Care. But this Australian is over it!

Why cannot our elected leaders and paid Officers answer simple questions and be held accountable for the policy and funding interventions they create into valued human service provision? We are projecting tens of thousands shortfall of residential aged care places by 2025 (ref 1) and now some 121,000 not provided with an appropriate level of community care packages short for older Australians already assessed by Government as needing community delivered aged care services. (ref 2).

Of that number, almost 57,000 had no package allocated. A discussion around the residential care funding issues can be found below. Parliamentarians prefer to support their side of the debate, but the Department of Health and Federal Parliamentary Library advice really does paint a helpful and insightful picture into this matter of “funding cuts”.

I shall leave it to you to decide. But if you were to ask me, a return to the residential aged care sector of the $1.2 billion in ACFI funding cuts, along with a requirement for providers to sign off on their direct care staff ratios, would provide, on average, an immediate return to a ratio of 3.2 Hours per Resident per Day (“HRPD”), and begin a move to the 4.3 (or from my research, 4.2) HRPD as soon as possible.

Recent changes:

ACFI subsidy expenditure has been growing more quickly than expected. The Australian Government believes the unexpected growth in claims cannot be explained by an increase in the frailty of residents, although many in the industry disagree. In order to rein in expenditure, around $1.7 billion in savings over four years were included in the Mid-Year Economic and Fiscal Outlook 2015–16 (MYEFO) and the 2016–17 Budget, to be achieved through changes to ACFI scoring and subsidy indexation. Despite these savings, residential aged care expenditure was still forecast to grow at around 5.1 per cent per annum.” A summary of the impact of these two difficult measures can be found below – https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Librar y/pubs/rp/BudgetReview201617/AgedCare 

“Rein in expenditure.” Is that not just a euphemism for a cut to funding?

You decide. Nice chatting!

References:

Ref 1- Aged Care Financing Authority, ‘Sixth report on the Funding and Financing of the Aged Care Sector’ (Aged Care Financing Authority, 2018), 36.

Ref 2 – Department of Health, ‘HOME CARE PACKAGES PROGRAM Data Report 4th Quarter 2017 – 18’ (Department of Health, 2018), Table 7, 11.

Image: Courtesy Business News.

What to do with a Royal Commission?

I am a person with no clinical or “care” background. But after almost forty years in senior management and executive roles across the spectrum of health and aged care – particularly aged care – I have gathered some insights into the nature of care being provided throughout our care services.

And before I suggest anything more, let me say this – my view is that if the major hospitals around Australia – public and private – were put under the same scrutiny and regulatory framework that residential aged care services are for the quality and accreditation of services that are provided in and through them, we would see hospitals falling into sanctions.

I am of the view that we have an aged care system that is too focused on beating the regulatory compliance framework as opposed to funding and providing appropriate levels of care and support to all clients.

On the one hand I am an incredibly strong advocate of high quality services accompanied with some form of accreditation. On the other hand, I believe we have an aged care accreditation system that we can really ill afford.

It underpins inadequate funding levels that cannot provide enough resources for many providers to meet the expressed needs of care for residents. In the same way, our community aged care system is creaking because we cannot provide enough funding for the community aged care packages assessed by the Australian Government as needed by our citizens.

I hear staff all over Australia clamouring, not always for more wages, but for more pairs of hands to do the work. To do more than the system underpins…To go the extra mile… To sit for a few minutes when that is what the client really wants, and really needs… To spend time hearing what the real story is…

To quote a UK study of its Home Help services from the early 1980s – “Too much Charring and not enough Chatting”.

I could ask the question – Which provides more care, the Chatting or the Charring? Neither is necessarily more correct, but often we cannot even get to the question. The bureaucratisation of aged care is with us and the paperwork must be done at our own peril.

I have colleagues that will not (at this time) support minimum staff ratios. Quite rightly they see them as an un-affordable cost under the current funding methodology. How sad that we do not all see them as providing perhaps the single greatest opportunity right now to see a reduction in abuse, and a reduction in short cuts in care. How sad that we do not see minimum staff ratios as an opportunity to support our staff and see a visual improvement in the increased in quality of care. But implementation of minimum staff ratios will be quite costly.

I am still of the view that in Australia we have one the best aged care systems in the world. But for a range of reasons it is creaking.

Let’s all is to consider how much of a cost is there to stop, take stock, and with the next round of changes, really consider the long term impact of where we are heading and fight more intensely to protect the rights of those who are dependent upon us, the general public, for their livelihoods?

And who knows – the Royal Commission might investigate several inter services aspects around care of our elderly folks? One matter that I have discussed for the past decade is how much more proactive care we can provide in our aged care facilities, that might actually have a positive, beneficial impact on our national health and hospital care services.

In the past twenty years we have missed the opportunity to think outside the square with respect to fixing major State based hospitals. As a “cohort” of patients, frail elderly people are significant and frequent users of hospital services. Perhaps if we reviewed the aged care sector and its inherent possibilities we might find better solutions to our hospital problems.

Chatfield’s cartoon below was first published by me in December 2010 in an article containing many of the words in the commentary above. Not much has changed it seems!

To fix hospitals, first fix aged care!

I get it… Do You?