Unintended consequences

In the recent progress report on the government’s implementation of the recommendations of the aged care royal commission, Inspector-General of Aged Care has highlighted a need to evaluate measures already in place and make any necessary adjustments.

The 2024 Progress Report – tabled in parliament on 2 August – assesses how well the government is doing in implementing the 148 recommendations of the Royal Commission into Aged Care Quality and Safety.

Commenting on the progress, Acting Inspector-General of Aged Care Ian Yates said the government was substantially on track – provided it gets the Act through for a July 2025 commencement. “Significant positive reform has happened, but we need to sustain the momentum,” Mr Yates told Australian Ageing Agenda.

Of those areas requiring urgent attention, the report calls on the government to consider whether individual elements work optimally together with a view to increasing complementarity and resolving conflicts.

“All the players need to sit down and start thinking through how we work out what the overall impact of these many, many changes is,” said Mr Yates. “Are we actually getting better outcomes for the older people and their families?”

It will require a cooperative effort among all stakeholders with government in the lead “because there are unintended consequences as one measure butts up against another measure,” he said.

This comes in response to stakeholder feedback and concerns about where the design of one program – for instance care minutes – impacts adversely on the goals of another, resulting in reduced access to holistic quality care.

“It has played a role in terms of allied health, for example, and that’s a very important consideration if you want a restorative-focused aged care system,” said Mr Yates.

Mandated care minutes – a sector-wide average of 200 minutes of care per resident per day including 40 minutes of direct registered nurse care since October 2023 – are meant to ensure better care. But it has led to a reduction in allied health care for aged care recipients – such as those services delivered by occupational therapists, physiotherapists and exercise physiologists – as only the minutes of personal care workers and nurses count.

Unintended consequences is probably a kind way of putting it.

Dr Chris Atmore

Allied health has been marginalised according to national peak body Allied Health Professions Australia – which has been strong in its advocacy about the impact of care minutes.

“Unintended consequences is probably a kind way of putting it,” AHPA’s policy and advocacy senior advisor Dr Chris Atmore told AAA. “We’re not saying it was malicious, but we do think that allied health has been overlooked; marginalised.

“We do call the government out on that to some extent, because it was very clear from the royal commission’s final report that allied health was critical to aged care, particularly to reablement. And they made a number of allied health-focused recommendations, which haven’t been taken up in the implementation.”

AHPA member Occupational Therapy Australia has been recording the impact on its members through surveys. Following the October 2022 introduction of the Australian National Aged Care Classification funding tool – with funding for the incoming care minutes – surveys show many OTs were given fewer hours, redeployed out of their clinical roles or fired, said Christina Wyatt – OTA’s professional practice advisor of aged care.

“Many reported that residents are going without essential allied health services like occupational therapy resulting in reduced health and wellbeing outcomes. This was the same feedback obtained in a survey conducted across the profession at the one-year anniversary of these reforms.”

In April this year, OTA, in partnership with AHPA and other allied health peaks, held a roundtable with Mr Yates to hear from allied health clinicians and aged care consumers.

“Consumers and carers highlighted the valuable support of allied health professionals but raised issues around lack of service access or equipment access and the implication this has had on function and wellbeing,” said Ms Wyatt. “They also highlighted the inconsistency in services available between home based aged care compared to residential aged care and the significant financial and carer burdens many are having trying to source the allied health support they’re being told isn’t available to them through aged care funding,” she said.

It’s not just allied health subject to unintended consequences. Other issues highlighted in the report include staff who are poorly trained or skilled in, for example, dementia or palliative care, or have a bias that mitigates against a restorative or enablement approach to care.

“You get a situation where you have providers who have met their care minute targets but have effectively relatively untrained staff,” Mr Yates told AAA. “We are critical, for example, of not implementing the royal commission’s recommendation that everybody should have dementia training… the vast bulk of people going in, particularly into residential aged care, have cognitive decline, and there’s no requirement that the people looking after them understand how to deal with that.”

The issue is both about whether this situation puts consumers in physical harm, as well as the potential for restorative measures, said Mr Yates.

“Unintended consequences are inevitable. What is not inevitable is that we ignore them, and therefore we need to look beyond ticking the recommendations off and look at the impact on the system as a whole.”

The Department of Health and Aged Care has been monitoring the impacts of the reforms implemented so far including the AN-ACC funding model and care minute and 24/7 nursing requirements.

To date, the care minutes policy has been adjusted to allow enrolled nurses to count towards 10 per cent of RN targets from 1 October 2024. The same day the requirement increases to a sector-wide average of 215 care minutes per resident per day, including 44 minutes of direct RN care. 

“This adjustment will incentivise providers to continue to recruit and retain this important part of the aged care workforce, and support providers to meet care minutes in the context of workforce shortages,” said the spokesperson.

That doesn’t address the impact on allied health.

On that, the IG report supports a review of the impact of care minutes on the provision of allied health in residential care and suggests the department consider whether other policies, such as legislating a requirement for providers to spend all their care subsidy on the provision of enablement-focused care, could offer an effective means of realising the royal commission’s intent.

This [evaluation] will be an opportunity to look closely to see if there are any unintended consequences of the care minute measures recommended by the royal commission

Department of Health and Aged Care

The department intends to undertake an evaluation of the care minutes and 24/7 registered nurse measures in 2025-26.

“This will be an opportunity to look closely to see if there are any unintended consequences of the care minute measures recommended by the royal commission and investigate if any policy refinements are needed to more effectively realise the royal commission’s intent,” a spokesperson from the department told AAA this week.

The department also pointed to provider financial and operational data published on My Aged Care via the Find a Provider tool since February to provide transparency into provider expenditure on the care of residents.

“It includes details of all income received as well expenditure on care including allied health spending, wages, food and other key items as reported by providers,” the spokesperson said

Other work underway to support the delivery of allied health in residential aged care includes the development of a staffing quality indicator on allied health by 1 July 2025 and the Strengthened Aged Care Quality Standards through the new Aged Care Act, the spokesperson said.

“These strengthened standards create clear expectations around the role of multidisciplinary teams, including allied health professionals, in the provision of coordinated and comprehensive clinical and personal care.

“The strengthened standard on clinical care also highlights the distinct role of allied health professionals in supporting reablement and maintenance of functional capacities for residents.”

AHPA backs calls for demand-driven aged care

Overall, the 166-page report focuses on issues related to access and navigation, aiming to focus attention on the difficulties that people are still experiencing in obtaining aged care.

It calls on government to introduce a more seamless, demand-driven aged care system which, together with a rights-based legislative framework, would deliver the transformation the royal commissioners recommended.

Having it rationed and having long waiting times creates other problems, both for people and government

Ian Yates

The IG wants the government to reconsider a needs-based approach – an unrationed aged care system – in the coming months. A demand-driven system is necessary because it is so critical to the achievement of the overall objective of the royal commission, said Mr Yates.

“Having it rationed and having long waiting times creates other problems, both for people and government. For example, people sitting in a hospital bed because they can’t get a home care package or a nursing home bed,” Mr Yates told AAA.

The report, and Mr Yates, argue an on-demand system poses no threat to budget integrity nor is it inconsistent with ensuring the financial sustainability of the aged care system.

“At the moment, you’ve got budget uncertainty because it’s relying on political pressure related to the waiting list, whereas one of the most sustainable social programs we have right now is the age pension.”

On reconsidering an unrationed approach, the Aged Care Taskforce and government have considered “projected demand for in-home aged care services … as it seeks to better align services to growing need in the community,” the departmental spokesperson told AAA.

“Government is expected to release its response to the Aged Care Taskforce and the final design and funding of the Support at Home Program in due course.”

The sector is still waiting on the government’s response to the taskforce report, which was released in March.

However, one of the criticisms Mr Yates made of the taskforce report is that it failed to address the royal commission’s call for a new planning regime. “The taskforce report did not make any findings or conclusions regarding rationing versus needs-based or make any recommendations or target any of the funding principles towards needs-based planning,” said Mr Yates in April.

There has to be a commitment and a clear definition that allied health is a fundamental part of direct care

Dr Chris Atmore

Atmore and the AHPA welcome the IG’s call for an unrationed approach to aged care and his arguments for its financial sustainability.

“From an allied health perspective that’s important because a lot of our work is aimed at early intervention and prevention,” Atmore told AAA. “We all know, and have known for some years now, that’s cheaper than waiting until you have to hospitalise the older person, and perhaps have surgeries and other high-level interventions, or that they have to move out of home because they can no longer be supported there, and they end up in residential care.”

It makes sense that providing the targeted types of allied health that every individual needs in the first place should forestall at least some of those unnecessary costs further down the track, she added.

“Alongside the needs-based focus of aged care, there has to be a commitment and a clear definition that allied health is a fundamental part of direct care, alongside nursing and personal care, and a government commitment that direct care and aged care should always be funded by government.

“We’re still waiting for the response to the taskforce report, but it’s up to them to work out how to do that. We’ve certainly made some suggestions, but fair enough that if people want genuine luxuries that they might have to pay for those themselves to live in a posh environment, or whatever it might be. But these are fundamental rights to aged care that we’re talking about, and our view is that the government should be paying for them.”

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