Legislating ratios and retaining state-owned aged care facilities are key policy platforms for the new Labor Government in Victoria. But is it good policy?
The Victorian aged care sector is dealing with many of the same challenges as the rest of the country, such as those around transitioning to consumer directed care, workforce, the now ceased payroll tax supplement and departmental functions related to online claiming and means testing.
However, a change of government is bringing some unique activity to the state.
Most notably, as per its pre-election promise, the new Labor Government led by Daniel Andrews is pushing ahead with becoming the first Australian state to legislate nurse-to-resident ratios in state-owned aged care facilities.
The State Government is committed to enshrining in law the ratios in the nurse’s current four-year enterprise agreement ending 2016, the office of Minister for Ageing Martin Foley confirmed to Australian Ageing Agenda.
Those ratios for aged care are one nurse for every seven residents plus a nurse in charge on morning shifts; one nurse for every eight residents plus a nurse in charge on afternoon shifts; and one nurse for every 15 residents on the evening shift, according to a spokesperson for the Australian Nursing and Midwifery Association Victorian Branch (ANMF Vic).
The State Government says the legislation will protect the public by ensuring the current ratios continue in future in all Victorian public hospitals and public residential aged care facilities.
The policy is supported by the ANMF Vic, which says ratios serve to guarantee the minimum number of qualified nurses on each shift to ensure high quality patient care and safety.
However, the aged care peaks say there is no evidence that ratios result in better quality care.
While this policy is not sector-wide, it does affect the 185 state-owned residential services, 53 of which are Leading Age Services Australia (LASA) Victoria members.
LASA Vic CEO Trevor Carr says his main objection to the policy is it lacks an evidence base.
“The real issue that nobody ever seems to ever want to talk about is there is absolutely no evidence whatsoever that suggests that having the ratios in place in the public sector provides a higher or a better living environment for the residents of those care facilities,” Carr tells AAA.
“The key thing is to make sure you have got the appropriate mix of skills to provide for the needs of the residents both for their daily living needs and for their clinical needs.”
This view is shared by Aged and Community Services Australia (ACSA) manager government relations and policy Heather Witham, speaking on behalf of ACS Victoria.
“There are accreditation guidelines and we are assessed for whether we have adequate staffing at that time,” Witham tells AAA.
Ratios are really an arbitrary measure, she says. For example, in one situation there may be six residents who are all quite well so less nursing staff is needed, Witham says.
Looking for evidence
A 2011 Victorian Department of Health Report, Innovative workforce responses to a changing aged care environment, also emphasised the lack of evidence.
The report highlighted that Victoria’s public sector patient ratios, which were introduced in 2001, arose from an Australian Industrial Relations Commission decision rather than a strong evidence base.
It found that California appeared to be the only other place in the world with legislatively mandated nurse-to-patient ratios in its hospitals and no evidence of ratios being used in residential aged care.
The report concludes that, based on the literature review, there is little evidence to sustain an argument in favour of ratios and instead calls for staffing methodologies that take account of a broad range of variables and contexts.
Emeritus Professor Rhonda Nay from La Trobe University’s School of Nursing and Midwifery led that departmental report and is a former director of the Australian Centre for Evidence Based Aged Care.
She says there is little good to say about nurse-to-resident ratios. “The evidence shows that the quality of care and staffing is far more important than the quantity of nurses,” Nay tells AAA.
Minister Foley did not respond directly to a question from AAA on whether the government’s commitment to legislate ratios was evidence-based. Nor did his response address a question on the influence ratios in state-owned aged care might have on the rest of the sector.
In the lead up to the November election then shadow minister for ageing Jenny Mikakos told AAA she believed that ratios in the public aged care system would set a standard for the entire sector.
But Carr says that any suggestion the government’s policy would flow beyond the public sector was both a concern and impractical.
He says the model risks over-medicalising aged care when it is supposed to be more of a homelike environment providing daily living and comfort, while, on a practical level, “it would close the system down overnight” as there are not enough nurses to distribute across the whole sector according to the ratios currently imposed upon the public sector.
“It is also a very high-cost model and it is not a model that is provided for within the approach taken by the funder, which is the Federal Government… I can’t see how from any practical point of view that would be anything that any government could possibly be seriously considering based on those two elements.”
Witham says ACSA is not too worried about any expectation of a flow-on affect.
“We really need to be provided with evidence that ratios actually improve quality of care before any of our members would consider implementing them,” she says.
Witham also points out the extra cost the State Government has to pay on top of the Commonwealth subsidy, a measure the not-for-profit sector would not have to do.
In response to AAA’s enquiry Minister Foley’s office says “it is not possible to specify the particular cost of Victoria’s nurse-to-resident ratios” due to complexities surrounding the commonwealth being the aged care regulator and funder but not the prescriber of set staffing arrangements.
However, mandated ratios in aged has some support in Canberra with Senator Glenn Lazarus, Leader of the Palmer United Party (PUP) in the Senate, saying in February he was going to lobby the federal health and social services ministers over the issue.
His announcement followed meetings with national ANMF representatives, who said they were “heartened” by the senator’s commitment.
At the time of writing, the results of his lobbying were unclear, but AAA’s report online drew much reader commentary.
Halting the sell-off
Legislating for ratios isn’t the Andrews Labor Government’s only aged care policy; it has also confirmed its commitment to end the sell-off of state-owned aged care facilities, which as at the end of December 2014 totalled 185.
The sell-offs have stopped and any residual issues relating to actions of the previous government will continue to be reviewed as necessary, Minister Foley’s office tells AAA.
ACSA believes it is important to have a mix of services available so people have the greatest choice possible, Witham says.
“It is important to have aged care available to people in the areas where they need it. And it may need to be government funded because of the increased cost of providing aged care in these areas,” she says.
However, Carr describes Labor’s position as an ideological response that is at odds with the former Liberal government.
Leaving it up to individual agencies would be better, says Carr, who prior to joining LASA was CEO of the Victorian Healthcare Association, the industry body representing the Victorian public hospital and community health sector, for eight years.
Victoria’s public hospital sector has a distributed model of governance and includes 85 independent hospital boards across the state with around 68 in rural Victoria. Nearly all of those services have some aged care profile – either residential care beds or community aged care services, or both, he says.
“It really should be left to each individual agency to determine whether or not they can viably, sustainably and strategically be involved in the delivery of these services rather than it being a government policy.”
However, it is appropriate in some instances, particularly where market failure is clearly evident, he says.
On the new government generally, the peaks say they are looking forward to working with Minister Foley, who has quite diverse ministerial responsibilities across four portfolios.
His ageing portfolio also includes housing and disability and Foley is also the Minister for – Mental Health; Equality; and Creative Industries.
Minister Foley says his government supports older Victorians leading healthy, dignified and productive lives whether they are in work, retirement, volunteering or caring roles.
“Health services, support services for people living in the community and residential aged-care services are all important priorities,” he tells AAA.
Carr says the housing, disability and ageing combination is consistent with the election blueprint that LASA Vic put forward.
“Combining those different areas of responsibility does provide opportunity for a more holistic policy response to a range of issues confronting people as they age,” he says.
“We will be quite keen to engage both on the industry specific conversations around aged care as well as the systemic policy responses around ageing communities.”
This article appears in the March-April issue of AAA.