History: Ever since Bronwyn Bishop and our politicians met the US con man Andrew Turner politicians and industry leaders, none of whom have had actual experience in the wards, have been enticed by the possibility of reducing the major cost of care - nurses. They have clung to the illusion that the aged are not ill -- they are simply getting old so don't need nursing and medical care.

Our leaders and businessmen keep coming back to it over and over again. They have steadily been eroding care by reducing the number of properly trained nurses year by year.  Because they don't collect and publish accurate information, they can continue believing and claiming "no evidence".

Registered nurses in nursing homes

Adequate staffing is critically important in aged care and yet providers and government have connived over the years to steadily reduce staffing numbers and skills.  Unlike the rest of Australia, NSW still had some regulations requiring registered nurses and an opportunity to get rid of that requirement presented itself.

Recent debate reignited in NSW

The debate has been reignited in NSW where the industry has urged government to consider removing the requirement that there be a registered nurse on duty in nursing homes at all times.  There has been an outcry from everyone who has anything to do with care - except for those who make money out of aged care - those whose success on the share market depends on their making even more and of course the politicians who support them.  The nurses union states the obvious, but stops short of saying that we can't trust the providers.

"The loss of this legislation would simply mean that we would rely on the 'good will' of aged care providers, who in many cases are there to make a profit – we know it and they know it."

Source: NSW Government shuts down debate on RNs in aged care - NSW Nurses & Midwives Association, 11 Sep 2015

I addressed the current conflict about staffing in NSW on the webpage Risks in the marketplace.  I quoted the responses of those caring for the aged when faced by the proposal to no longer require nursing homes to have a nurse on duty at all times.  This page is simply to highlight the widely differing views between those who actually deal with the aged and those who make decisions about aged care.  The latter are deaf to what they are being told.

Arguing against registered nurses

Industry argued that nurses were often not necessary for 24 hours and that this would create problems for many nursing homes.

Those who don't think we need registered nurses legislation

But Charles Wurf, the chief executive officer of Leading Age Services Australia NSW-ACT, the peak body for high-care operators, said the law was a hangover from the days when aged care facilities were primarily regulated by the states, but were not relevant now the system had shifted towards federal regulation.

He said it was flatly wrong that removing the law would negatively impact elderly residents.

Source: Plan to remove nurses from nursing homes - Sydney Morning Herald, 21 May 2015

Aged care providers and nursing unions in NSW are set to clash over whether to keep state legislation requiring aged care facilities to employ registered nurses at all times to oversee high care residents.

Aged and Community Services NSW & ACT CEO Illana Halliday told Australian Ageing Agenda that ratios and staffing requirements were a blunt measure that did not respond to the actual needs of clients and would contribute to unsustainable costs.

The peak body estimated the direct wage costs of employing an RN 24/7, for a current low care 70-bed facility would be $500,000.

Ms Halliday said a requirement to have an RN on duty at all times in every facility with a high care resident would also be impossible to manage due to a lack of available staff and would be a waste of limited resources.

She said while skilled RNs were necessary in the provision of palliative care or short-term acute care in a facility, not all high care residents would require an RN to meet their needs.

“It is probable that many residents with a high score in ACFI may still not need an RN, as the care they require is not acute or curative, it is about comfort and quality of life,” Ms Halliday wrote in a ACS NSW & ACT position paper.

Source: Providers push to review RN staffing requirement Australian Ageing Agenda, 25 Jun 2014

if you need to refresh your memories, you can see the incredulous responses by linking to the press reports and reading the comments at the foot of the Australian Ageing Agenda page.  Coming from an industry leader, the suggestion that registereed nurses are only needed for acute and palliative care is weird. The industry is promoting the illusion that they are bound by professional codes and would not understaff.

Unopposed corporate interests are not and have never been restrained by professional codes of any sort.  Pressures within them seek to undermine or sidestep them.

CPSA highlighted the views of one opponent who acknowledged one consequence.

Phil Belletty, the CEO of Clarence Village, a not-for-profit aged care facility in Grafton, told The Daily Examiner that full time RNs could reduce the number of clients requiring hospitalisation, but this 'did not help the aged care facility’s bottom line.'

Source: Registered nurses reduce hospitalisations, but don’t help nursing homes’ bottom line – nursing home operator CPSA, 31 Jul 2015

The risks of doing without registered nurses

It means trusting the providers who exploit any loophole their can find to keep prices down.  But they are the problem and have been the offenders.

What will happen

Below is an example of the sort of thing that is happening. How many will behave similarly and, as in the explanations offered above, try to rationalise and explain it away. 

If the industry wants us to trust them, then they need to earn that trust.  If the proposed Community Aged Care Hub was in place, with an accurate data base recording standards of care and nurses on duty then a more flexible and risk free approach to staffing might be possible.  The market might then work.  But until then, we do require laws and staffing levels. 

Note in the extract below, that it is a not-for-profit operator that is doing this. They are increasingly copying for-profit providers:

The NSW Nurses Association (NSWNA) met with Fair Work Australia in Sydney yesterday to ask the independent body to step in and quiz the aged-care facility's owners on a number of redundancies and working conditions.

Waratah Village was owned and operated by Bland Shire Council until January 31, when council handed the reins over to the Royal Freemasons Benevolent Institution (RFBI).

The NSWNA says since the takeover, nine registered nurses have been made redundant and up to six enrolled nurses have resigned as a result.

The NSWNA says the two registered nurses left are co-managing Waratah Village and neither are rostered to work outside 8.30am and 5pm, Monday to Friday. 

-- The village previously provided 24-hour registered nurse coverage.

- -  the two registered nurses do not have the time to provide direct resident care or supervise the care service employees.

Source: Fair Work looks at aged-care sacking - Daily Advertiser, 28 Mar 2012

What we need to consider is the management culture in the nursing homes -- the way they think about this.  We get a glimpse into this from the Royal Australian College of GP's answers to questions they were asked, by the NSW senate inquiry.  They responded in writing. 

The nursing home referred to are unable to balance their need to restrict staff numbers against the importance of giving medication.  In the mind of at least one manager, staff restriction came before medication needs.  While the memo referred to below was withdrawn, the cultural significance remains.  Someone thought this was OK and someone in authority must have authorised it.

A GP from northern NSW advised that in June 2015, local GPs who have patients at a (de-identified) nursing home were memo-ed:

"... As you are aware, we have 80 beds in our (redacted) facility. Presently we have about 65 residents and of these we have 63 residents on 9 or more medications...

We have a large number of residents receiving Panadol t.d.s. and q.i.d. Unfortunately our staff are not able to administer the large volume of medication inc. the Panadols within the required time frame & as such the lunch time Panadols are usually not given... "

The GP advised that this memo was officially withdrawn by the nursing home management when they learnt of it. The situation described in the memo is:

  • Not uncommon in nursing homes
  • Indicates the increasing treatment complexity of the elderly residents in aged care homes
  • Indicates that RN staffing ratio is both inadequate and not keeping up with increasing complexity of care.

Source: Answers to Questions on Notice: Royal Australian College of General Practitioners NSW Inquiry into Registered Nurses, 2015

A Government Inquiry in NSW

The Labour and the Greens held a majority in the NSW upper house.  They initiated an inquiry that received many submissions.  This inquiry advised that registered nurses 24/7 should continue to be mandatory.  But this was really an exercise in futility.  The providers had the ear of government and the Labour party had been so corrupt that it was unelectable.  The important recommendations by the committee were rejected by government.

A parliamentary inquiry

After multiple petitions, the NSW parliament held an inquiry into the need for registered staff and interestingly looked at other staffing issues as well.

A lack of data on which to base decisions

The great difficulty for the politicians and those who believe you need staff is that Australia does not collect information about standards of care and staffing.  So the debate might have come down to credibility rather than evidence. In our society, senior executives enjoy almost unchallengeable credibility.  There is no data to refute their assertions because no one collects data any more!

It is interesting that actually collecting information on which to assess residents' nursing needs, setting out desired staffing requirements and then making these as well as each facility's staffing levels and the extent to which they conformed transparent was not considered by the inquiry.

I can only echo Baldwin's call for evidence based policy.

The most researched structural factor is ownership as it is a predictor of other factors that may influence quality such as staffing levels, organisational culture and financial performance.
------- most research studies using large samples have reported that residents in not-for-profit facilities enjoy better quality of care and have better outcomes than those in for-profit facilities.
- - - The evidence on indicators of financial performance tends to favour the for-profit sector.

Source: The Future of Aged Care in Australia: A Call for Evidence Based Policy The Policy Space, 22 Sep 2015

There has been extensive press coverage.  For more see the links below:

The Senate Inquiry

I have not read all of the material but the documents and the record of the sessions that I have seen are interesting and revealing. Its not only what was said, but what was not said that are revealing.

The submissions, other documents, the transcripts of the inquiry, the final report and the government's response can be found at this link

The recommendations

The NSW Inquiriy made multiple recommendations.  Those to the NSW government included recommendations for:

  • accurate data collection about the transfer of residents to hospitals in NSW
  • retaining the requirement in section 104(1)(a) of the Public Health Act 2010 for registered nurses to be on duty in nursing homes at all times but that exceptions could be applied for on a case by case basis
  • report on existing programs and incentives and investigate additional programs and incentives to support registered nurses to train and work in regional, rural and remote areas.
  • review alternative models of housing for older persons other than aged care facilities, including cooperatives and communal living that provide an on-site caretaker

In addition, they recommended that the NSW Government, through the Council of Australian Governments, urge the Commonwealth Government to:

  • introduce a number of steps to beef up commonwealth ”genuinely” unannounced visits to make them more rigorous
  • establish minimum staffing ratios in aged care facilities
  • establish a licensing body for aged care workers
  • require aged care facilities to make information about their staffing skill sets publicly available, including for it to be published on the ‘My Aged Care’ website
  • disseminate clear information about how to lodge complaints
  • take active measures to address the wage disparity between registered nurses in aged care facilities and registered nurses in the public health care system

In general the inquiry gave those pressing for better staffing almost everything they wanted but the opposition was the majority on this senate committee and the government who were generally in support of the industry were in a minority. The submissions and transcripts provide an interesting window into the divide in aged care in Australia and the way politicians behave!

The CPSA representing pensioners welcomed the findings. Labor’s Health Spokesman, Walt Secord, indicated that the report was unanimous urging the health minister to comply.

“CPSA welcomes recommendations regarding improving transparency about nursing home staffing and complaints, improving data collection, providing better training for aged care staff and strengthening the risibly ineffective accreditation system.”

“More broadly, this report exposes the failings of the Australian Government’s regulation of nursing homes, particularly in the area of staffing.

Source: Vindication: Government report recommends registered nurses be in nursing homes at all times Media Release CPSA 29 Oct 2015

He (NSW Labor Health spokesman Walt Secord) said. "Sadly, the evidence of the committee lined up in two disparate groups – those who wanted to protect nursing residents and those who wanted to protect the rivers of profit flowing into the pockets of commercial aged care providers."

The (NSW Nurses and Midwives) association has submitted more than 24,000 signatures on a petition to NSW Parliament that advocated retaining the positions.

Source: Parliamentary inquiry says nurses should be mandatory in nursing homes Sydney Morning Herald 29 Oct 2015

The industry took a rather different view and did not hear what the nurses and residents were saying. One wonders how close many of the industry representatives got to the bedside and how many had actually been carers.  How many senior executives came from the business world and how many from the nursing profession.

- - - but aged care provider peaks said they were disappointed with the report, describing some of the findings as “borderline offensive.”

“It’s implying that we are in some way not caring about the quality of care being provided, and that the current system is broken, and we don’t believe it is,” said Illana Halliday, CEO of Aged & Community Services NSW & ACT.

But beyond addressing the NSW requirement, the cross-party committee also called for sweeping changes to the national aged care regulatory framework.

The report noted there was “deep division” over the effectiveness of the Commonwealth’s aged care regulatory framework among the inquiry participants, which included providers and their peaks, GPs, nurses, unions, seniors advocates and researchers.

The accreditation standards did not prescribe the type of staff, qualifications required by staff or the number of staff who work in an aged care facility, the report noted. The way residential facilities were described by inquiry participants as being monitored and assessed against the accreditation standards was “troublesome,” it concluded.

Responding to the findings, Ms Halliday said the committee was seemingly misinformed about the current regulatory framework, and the accreditation process in particular.

LASA National chief executive Patrick Reid said the peak body held serious concerns about the report’s recommendations, which would impose significant costs on employers and government, and would unlikely improve outcomes.

Source: Aged care staffing requirements ‘too vague’ NSW inquiry finds Australian Ageing Agenda 4 Nov 2015

Government rejects Registered Nurse recommendations

The government responded to the recommendation on 29 April 2016 refusing to maintain the requirement that there be a registered nurse on duty at all times. It undertook to take up some other matters with the federal government. The Sydney Morning Herald commented on the number of important community and medical organisations that had lobbied strongly for registered nurses.  ACSA issued a media release praising the decisions as a “a great result for older people in NSW” and sent a letter of thanks to NSW members of parliament claiming this would “avoided around 4000 Care Workers losing their jobs” and keep “around 100 smaller facilities open”.

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