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Response to the Royal Commission’s (Counsel Assisting) eleven proposed recommendations on aged care workforce

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The Aged Care Workforce Industry Council acknowledges the Royal Commission’s (Counsel Assisting) eleven proposed recommendations on aged care workforce.

The Council makes four key observations:

  1. The recommendations address a number of areas that have been highlighted in both the Royal Commission’s Interim Report and Consultation Paper One. Furthermore, there is close alignment between several recommendations and A Matter of Care.
  2. Addressing workforce issues will require an approach that reflects the not only metropolitan locations, but also rural, regional and remote locations which constitute over 90% of the nation’s land mass (significantly impacting service delivery).
  3. Implementing the recommendations will require strong leadership and genuine co-design from those responsible for policy design (government) and policy implementation (industry). Together they must work with those being impacted (communities), and collectively there must be a commitment to do better.
  4. Embedding these recommendations, and ensuring that they protect those most vulnerable, requires responsive regulation – regulation that expects, encourages and sometimes requires continuous improvement and innovation. It need to also acknowledge the investment required to deliver lasting change.

The Council has provided this submission in accordance with these observations.

1. ALIGNMENT WITH A MATTER OF CARE

The Council will continue to build upon the foundation established by A Matter of Care, which:

  • Was industry-driven, and designed to grow and sustain the workforce to ensure it provides aged care services that can meet the care needs of our elderly now and into the future, irrespective of setting; and
  • Places the consumer at the heart of all decision making; and reflects a wider definition of consumer to include individuals, their families, informal carers and the community.

Over the past ten months since the Council commenced in May 2019, it has made great strides in its work to prioritise the Strategic Actions of A Matter of Care.

Examining the Strategic Actions in detail, together with their accompanying recommendations, the Council identified five overarching themes.

Looking in detail at the Royal Commission’s eleven recommendations we note the following alignment:

A Matter of Care Royal Commission
Leadership and re-shaping workplace culture
(Strategic Actions 5, 6 and 14)
Recommendation 11: The Aged Care Workforce Industry Council
Recommendation 10: Workforce planning
Collaborating on underlying challenges (Strategic Actions 1, 2, 8 and 13) Recommendation 1: Minimum staffing ratios
Recommendation 2: Increased transparency
Recommendation 9: Establishment of a registration scheme
Workforce design, knowledge, skills and competencies
(Strategic Actions 3 and 4)
ecommendation 3: Minimum qualifications for personal care workers
Recommendations 4 and 5: Education and training for medical practitioners
Recommendation 7: Education and training for registered and enrolled nurses
Attraction, retention and the right fit (Strategic Actions 7 and 10) Recommendation 8: Scholarships programs
Scoping the future
(Strategic Actions 9, 11 and 12)
Recommendation 6: Assessing projected demand for geriatric health services

1.1 Leadership and re-shaping workplace culture

The Council supports Recommendations 10 and 11.

With respect to Recommendation 10: Workforce planning the Council provides the following complimentary insights:

  • Providing aggregated information at the national level has been the predominant analysis and forecasting method for aged care. While metropolitan areas account for 80% of the population nationally, they only account for around 5% of the country’s land mass. Data aggregation fails to differentiate regional, rural and remote locations from metropolitan areas, obscuring the distinctive and unique challenges of non-metropolitan locations. Policy and program settings need a greater level of granularity for successful implementation – information that can be acted on
  • Building an industry-wide capability to undertake sensitivity analyses to gain an increased understanding of staff sentiment and localised uncertainties and opportunities is particularly important. Facilitating better connections between health and aged care datasets across governments and providers would be beneficial to inform workforce planning
  • The persistent pressures facing providers of health and human services – such as increased competition, changing community demands, and problems in securing a sufficient supply of workers – might be enhanced through greater innovation in how the care workforce is utilised, across jurisdiction, policy and sector divides
  • As system stewards, government has the opportunity to look at ways to address supply issues in these growing sectors – especially in regional, rural and remote Australia, given the economic impact of workforce shortages
  • Policy makers have an opportunity to work collaboratively, across portfolios and across jurisdictions, to create a new, dynamic operational scaffolding for workforce development – removing impediments to local innovation. Furthermore, policy makers, working with local leaders and the community, should be better positioned to consider how barriers to innovation can be reduced, especially in relation to integrated care.

With respect to Recommendation 11: The Aged Care Workforce Industry Council, the Council reinforces a previous message – that as a leadership group, it needs to support aligned activities that:

  • Promote a shared vision for change and a joint approach to solving workforce challenges through agreed-upon actions and approaches
  • Support mobilisation and alignment of public and private resources to support implementation goals, working in collaboration with government.

1.2 Collaborating on underlying challenges

The Council acknowledges the views being expressed by Recommendation 1: Minimum staffing ratios and Recommendation 2: Increased transparency, but would reiterate that the ratio debate has been long standing and does not take into consideration the experience levels of personnel.

It’s acknowledgement of these two recommendations is provided on the following basis:

  • Improved care through increased staffing levels, although they should be across the wider definition of the workforce1 and focus on addressing current and future job roles, job families, jobs pathways, career development – to enable the effective delivery of holistic care plans
  • Casemix based funding2
  • Adjusting skills to reflect the casemix, based on holistic care planning (in accordance with Strategic Action 6: Establishing a new industry approach to workforce planning, including skills mix modelling)
  • Increased total hours of care, noting the total additional hours defined in the report are in line with the findings of A Matter of Care
  • A rating system to provide consumers, their families and the community with greater transparency and informed choice regarding residential aged care providers3. The system must provide consumers with data that is meaningful for purposes of informed decision making. All providers must be capable of providing the data and the information must facilitate like for like analysis. The Council notes such a system should be developed through a process of co-design and properly address the issues raised in Section 1.1. The current one-way flow of information to the Department of Health cannot continue if the aged care system is to be transformed as defined in A Matter of Care
  • Alignment with Strategic Action 6: Establishing a new industry approach to workforce planning, including skills mix modelling. This strategic action adopts a holistic approach to workforce planning that focuses on a person’s clinical, functional, cognitive and cultural care needs – recognised as a living well model of care. This sees a shift from a predominantly nurse led model of care to a living well model of care.Accordingly, the workforce strategy emphasises that workforce planning needs to address current consumer expectations and the living well model. And moving from clinical care plans to holistic care plans, recognises the providers’ role (top down from management and the Board) to deliver that care.

The Council supports Recommendation 9: Establishment of a registration scheme and is currently working with the Department of Health on a scoping study to assess the viability of a workforce register. We understand the scoping study will examine

  • Existing models of registration
  • The objective for registration in the aged care setting, and principles of use – developed through a co-design process with the sector
  • Operationalising such a system across aged care and the pros and cons of registration.

The scoping study would be used to inform a proposed registration system for aged care, which would be validated through a consultation process.

1.3 Workforce design, knowledge, skills and competencies

The Council supports the following recommendations:

  • Recommendation 3: Minimum qualifications for personal care workers
  • Recommendations 4 and 5: Education and training for medical practitioners
  • Recommendation 7: Education and training for registered and enrolled nurses

These recommendations are aligned the following areas of A Matter of Care.

Strategic action 3: Reframing the qualification and skills framework—addressing current and future competencies

This strategic action is about reframing the qualifications and skills framework in order to focus on addressing new and emerging roles and job families. This recognises that consumers rely on a knowledgeable and skilled workforce to meet their evolving care needs, and that they value the relationships with the people they see daily in a variety of settings, such as Personal Care Workers and functional health specialists.

A Matter of Care’s analysis of the current state of current workforce architecture highlighted the value of the Personal Care Worker role is underestimated; and that Personal Care Worker roles have a much bigger impact in residential facilities. They are especially important in home care settings as they are often the only aged care work the client sees on a regular basis. Further, Personal Care Workers form the majority of the aged care workforce and are the eyes and ears of the entire aged care system. And they spend the maximum amount of time with consumers and work with them daily in the closest proximity. It is important that we recognise Personal Care Workers as differently skilled employees for different tasks, who collectively represent a growing part of the workforce.

Strategic action 4: Defining new career pathways, including how the workforce is accredited

This strategic action aims at supporting an agile workforce by re-thinking and opening jobs pathways and career options. Specifically it looks at defining new career pathways including accreditation.

It recognises the role of nurses, who are skilled practitioners, leaders that support teams, an integral part of delivering holistic care, and who play key roles in terms of system governance and counselling complementary workforces.

The workforce strategy identified that existing structures and job roles within aged care organisations do not currently allow for realistic career progression. Specifically, several pathways could be opened up:

  • Extended levels within the Personal Care Worker job family
  • Recognising the role of nurses – skilled practitioners, leadership, holistic care, evidence-based competencies and working in teams
  • Defining new and emerging roles that support the consumer experience, such care coordination or care team leaders.

Strategic Action 9: Strengthening the interface between aged care and primary/acute care

Older Australians have increasingly complex care needs that frequently require multidisciplinary services drawn from across aged, health and disability care.

Health care and wellbeing for the consumer needs to consider their stage in life and personal goals. Care systems should also be focused on maintaining wellness, supporting consumers to manage chronic conditions and promoting reablement rather than on providing episodic treatment for acute care needs, which is where the current emphasis lies.

Preventative care and maintaining wellness are critical to supporting older people to remain healthy and independent for longer. And there needs to be a frank discussion across the social and health care industries and all levels of government about how to restructure care and design more flexible funding mechanisms that support consumers to transition more easily between Commonwealth, state and privately-funded services.

A constructive dialogue across the social and health care industries and all levels of government is necessary to shift attitudes – to promote better integration of services across health, aged and disability care.

1.4 Attraction, retention and the right fit

The Council supports Recommendation 8: Scholarships programs, noting they should not be restricted to nurses and should be considered in the context of a wider definition of the aged care workforce and also our comments around a living well model of care (refer to Section 1.2).

The Council notes this recommendation further supports A Matter of Care: Strategic Action 7: Implementing new attraction and retention strategies.

Making progress with attraction and retention will depend substantially on the other strategic actions. And an industry-wide approach is needed to attract the ‘right’ people to work in the industry:

  • Action is required across the industry ─ nationally, regionally and locally – to change the way jobs are characterised, described and advertised.
  • We need to learn from what works and harness good practice, for example:
      • Building on those factors that attract top talent – such as passion for the work, previous experience (informal and paid), job availability and opportunity, flexible working conditions, career pathways to similar employment (especially health care and social assistance)
      • Addressing factors that discourage top talent – such as poor industry perceptions, limited career pathways, low paid low status roles, organisational cultures
      • Supporting and capitalising on work placements, student placements or work placements to create a pipeline of candidates.
  • Recognising that employee induction and on-boarding is fundamental.

1.5 Scoping the future

The Council supports Recommendation 6: Assessing projected demand for geriatric health services In doing so, we highlight that:

  • Access to meaningful data (particularly forecasts of population ageing) are essential to make informed decisions around workforce deployment.Current data capture (the right information at the right level), data curation and management practices (data architecture, dictionaries, libraries, metadata) are inadequate for the purposes of informing policy or program settings when looking at beyond aggregate positions.A level of effort required to consolidate actionable information, from across a number of interdependent sectors, and apply this collective knowledge to better inform aged care policy.And without the right data infrastructure and architecture, any steps to improve planning, transparency or navigation will incur higher ongoing costs – with limited ability to automate.Small-area population projections suggest that many regional and rural communities are likely to be characterised by strong growth in the number of aged Australians, with a dwindling proportion of children and a shrinking proportion of the population of labour-force age. In these locations, fewer workers will be available to help meet the service needs of older Australians, and extensive planning will be required to ensure that government is able to provide the health, aged care and other services needed by these populations. Current literature highlights the decreasing carer ratio, which is an issue magnified in locations where workforce shortages are an issue generally. This decreasing ratio makes it increasingly difficult to ensure continuity of aged care services for those wishing to remain in-place. And notwithstanding the clinical issues, there is an impact on their quality of life when older Australians have no option but to relocate.s the Commission stated in 2019, rapidly declining ratios have implications not only for the financing of aged care but also for the aged care workforce. In some regions there will be far fewer workers to draw on to meet the rapidly growing demand for health and aged care services (Royal Commission into Aged Care Quality and Safety, 2019).The investment infrastructure to support a nuanced discussion around the above is inextricably linked to the delivery of Strategic Action 12: Establish an Aged Care Industry Growth and Research Translation Centre. This Strategic Action is in establishment phase with the advice of the Committee. It is an essential component for improving and growing workforce through translation of the best available evidence and promoting proven innovations.
  • Framing workforce issues in the context of a living well model of care (Strategic Action 6: Establishing a new industry approach to workforce planning, including skills mix modelling) is essential to ensure we keep the consumer at the heart of all decision making (recognising the consumer includes individuals, their families, informal carers and the community).A Matter of Care reinforces a holistic approach enables differentiated service offerings, improved consumer understanding of what to expect, together with greater transparency to the consumer and their families. Applying a holistic care model places a greater emphasis on emerging roles such as dementia care and diversional therapists. It also requires functional health roles to be better understood as part of the total workforce skills mix.Therefore, as an industry, there is a need to transition to a higher standard. This is essential if the industry is to move ahead of community expectations and be able to begin a much more nuanced and sophisticated discussion around staffing levels that reflect a providers’ aggregated care planning (and intervention) requirements, rather than using a ‘one size fits all’ approach.

2. ADDRESSING WORKFORCE ISSUES

Addressing workforce issues will require an approach that reflects not only the metropolitan locations, but also rural, regional and remote locations which constitute over 90% of the nation’s land mass (significantly impacting service delivery).

This remains a common issue across human care and social services settings – and a one size fits all approach does not work.

Furthermore, we note there are major residential care funding issues in regional and remote locations:

  • Overall 51% running at an operating loss, 65% outer regional and remote
  • From an EBITDAR position, 27% running at a cash loss, 47% regional and remote (of which the majority are government or community operated)

The Council’s composition provides it with direct access to a significant part of the sector. Through the national networks represented by Council Directors, there is an opportunity, working in collaboration with the provider peaks, to directly access providers on mass. A number of these settings extend well into regional, rural and remote locations. Furthermore, the strong connection with the Remote Accord (Strategic Action 11) means that insights are readily accessible and innovative workforce models more readily able to be trialled and assessed.

Based on insights gained through the Council’s broader network, the Council strongly believes that workforce initiatives designed by the community for their community have proven to be more innovative and successful than those centrally determined:

  • Logistical impediments arise when delivering health and social services in regional, rural and remote areas – affecting the efficiency of operation, the effectiveness of the workforce, and funding needs
  • Such constraints apply to aged care services where geographical isolation and low population density makes service delivery more costly per client
  • The effectiveness of care can be compromised when the community, service provider or individual worker does not have access to the necessary resources
  • While funding is a significant issue in its own right, the complexity of the service delivery environment outside of metropolitan areas highlights the need for tailored macro-policy settings, including funding allocation and infrastructure, to complement any community, provider or worker-level initiatives.

The Council remains cognisant of the limitations of compelling workforce innovation through a centralised approach. Instead we believe that empowering local communities and their service providers with appropriate support to explore innovations that best meet local needs. The Council advocates for:

  • Proactive engagement with local communities to encourage examination of the support required to activate key supply levers (attraction, training, retention)
  • Devolution of these discussions to the local level can also partly address the perpetual contest between Australian, State and Territory Governments about their competing roles in orchestrating care systems. Furthermore, dialogue at the COAG level is still needed to address the disparity between salaries for registered and enrolled nurses and Personal Care Workers in the aged care and acute health sectors.
  • Greater experimentation, through the Centre for Growth and Translational Research (Strategic
    Action 12) would enable governments and the sector to commission new workforce-focused research, which national strategic delivery partners could help to translate into practice
  • Similarly, providers with a national network could be better supported to share and search out the lessons from others’ experiences with innovation.

3. IMPLEMENTING THE RECOMMENDATIONS

Implementing the recommendations will require strong leadership and genuine co-design from those responsible for policy design (government) and policy implementation (industry). Together they must work with those being impacted (communities), and collectively there must be a commitment to do better.

The Council’s commitment to implementing A Matter of Care reflects the above sentiment, and so it working with the sector, government and the community to embed long-lasting cultural change, which fundamentally means inspiring people to act differently.

The Council fully supports the Royal Commission’s statements that addressing the significant challenges will require new thinking; it will require policy makers and the sector to take some risks…[and that] not every initiative will succeed. This must be accepted. What future generations will not forgive is an unwillingness to learn from the mistakes of the past.”

Consultation by the Council reinforces that community, government and the industry are all motivated by a common desire – to create a better, more sustainable aged care system. And there is growing support for providing unrestricted, long-term support to networks that have the greatest community impact.

And the Council is mindful that in the midst of the significant challenges being faced in our industry, the Council must take a leadership role and look beyond the horizon so that we can bring the sector together build on the social capital that already exists within the workforce and their communities.

4. EMBEDDING RECOMMENDATIONS

Embedding these recommendations, and ensuring that they protect those most vulnerable, requires responsive regulation. That is, regulation that expects, encourages and sometimes requires continuous improvement.

The Council views regulation as the system of governance that steers the flow of events (i.e. the Department of Health), rather than a definition limited to enforced compliance with rules (i.e. the Aged Care Quality and Safety Commission). Notably:

  • An effective regulatory framework should make the case for regulators to improve compliance by understanding the behaviour of those they regulate. An unintended consequence of a regulatory system designed to ensure that people cannot choose to do what is wrong, is that they can no longer choose to do what is right. They no longer choose at all, they merely comply (Senate Economics References Committee, 2014)
  • Maintaining regulation that is fit for purpose requires working with those impacted to understand how they experience regulation. Regulators need to engage continuously with stakeholders, even when there is no ‘burning platform’, so they are alert to emerging issues well before they escalate
  • Continuous improvement means discovering lower cost ways to achieve regulatory outcomes, and in achieving better outcomes. These objectives are intertwined because when compliance costs fall, compliance tends to rise.

The Council strongly believes the posture of a responsive regulator is to make certain the relationship with all regulated entities is based on mutual respect, reciprocated trust, authentic consultation, genuine negotiation and a shared recognition of common purpose. Ultimately, resilient systems favour stewards (regulators) that anticipate, monitor, learn and respond, as compared to those that seek to command and control.

IN CONCLUSION

The Council recognises collaboration is essential for the industry to be open to engagement with the parties that manifestly share in having a respected, skilled and well supported workforce.

This collaboration is required across the sector, all levels of government and the community – to reshape how Australia views aged care – as an increasingly relevant sector that will undoubtedly be a social and economic driving force for the country now and into the future.

The Council welcomes the opportunity to discuss this response with you in further detail, and invites the Royal Commission to participate in a Council meeting.

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