Mandated minutes ‘fundamentally flawed’

There are fundamental flaws in how the required minutes of care are being allocated and enforced, writes Mark Sheldon-Stemm.

The required minutes of care being allocated and enforced don’t add up, writes Mark Sheldon-Stemm.

The introduction of mandated care and registered nursing minutes from the 1 October 2023 will require residential aged care providers to report on their success, or otherwise, to meet them. Those unable to meet the required minutes will be under the scrutiny of the aged care regulator.

Mark Sheldon-Stemm

The Department of Health and Aged Care has recently updated care and RN minute targets from 1 October for each Australian National Aged Care Classification class.

However, there are still fundamental flaws in how the minutes are allocated and therefore with how the Department of Health and Aged Care and Aged Care Quality and Safety Commission are going to approach the regulation of providers.

Firstly, the minutes allocated to each class for RNs and total care from 1 October are incorrect with the minutes skewed more favourably towards the lower-need classes (classes 2-7) rather than the higher-need ones (Classes 8-13 and 1). This reverses rather than corrects the outcome under the current settings – as discussed in a previous article – where the minimum minutes are more favourably skewed towards higher-needs residents. Our cost of care studies, carried out since 2016, show a different set of minutes for each class.

Secondly, the requirement for all residential aged care providers to have an average of 40 minutes of RN time per resident per day is not capable of being met due to the lack of RNs in Australia. The maths is simple. Take the number of residents in homes around Australia and allocate 40 minutes a day to them.

The result is around 25,000 full-time equivalent RNs are required to work in aged care, which equates to 35,000-40,000 actual RNs. The last census showed just over 20,000 full-time equivalent RNs (32,500 actual RNs) working in the sector. So the requirement doesn’t add up. The easy solution to this is to include enrolled nurses as part of the nursing minutes. After all, RNs are not going to come from the hospital sector as it is also struggling with RN shortages.

Thirdly, the minutes fail to include the need – and cost – of lifestyle and allied health staff. As these are important areas of care, they should also be reflected in the minutes.

Fourthly, the AN-ACC funding does not match the minutes allocated. Having conducted numerous costing studies for providers around Australia, it is clear the funding does not cover the cost of these minutes. In other words, providers aiming to meet their care minute and staffing requirements could sink financially. This is at a time when most providers are already running at a loss

Finally, there is the adage – quality versus quantity. We all know that having more does not always mean a better service or better outcomes. Taking comfort from meeting the minutes does not equate to good quality care and this may be the Aged Care Quality and Safety Commission’s Achilles’ heal.

Addressing these issues does not need to be difficult but there must be consensus on making the changes. I suggest:

  • adjusting the overall mandated minutes to reflect evidence-based care needs
  • revising the RN minute requirements so they reflect what can be met by the workforce
  • including time for lifestyle and allied health staff
  • funding that matches the true cost of care.

I have been in aged care for a long time so I understand changes are slow to come about. I also understand that even though policymakers are often aware of flaws, they are challenged by being able to address them before it is too late for many providers.  

But I do not understand why more providers are not jumping up and down about this change coming in six weeks’ time. Or are they simply brain dead from all the reforms?

Mark Sheldon-Stemm is principal of Research Analytics, and chief executive officer of ValleyView Residence

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Tags: AN-ACC, care minutes, mark sheldon-stemm,

6 thoughts on “Mandated minutes ‘fundamentally flawed’

  1. I certainly agree with you Mark, about the need to mandate allied health minutes, and the Achilles heel of the regulator. Nobody seems really interested in how the current paucity of allied health (4.55 minutes in the last Quarterly Financial Snapshot – just over half of the 8 minutes found 3 years ago by the Royal Commission to be woeful) aligns with quality service obligations. And of course if an adequate level of allied health isn’t mandated, there isn’t much incentive for providers to use their AN-ACC funding for allied health when they may be struggling to reach mandatory targets. But is anyone listening? – Chris Atmore, Manager, Policy & Advocacy, Allied Health Professions Australia

  2. As you suggested at the start of your article, providers are defeated by a bureaucracy with a hundreds of reform projects, and the spectre of sanction for any failure.

    The goverment trumpets record funding increases for aged care but this is not a real increase as all money is linked to either increased staffing minutes or increased pay rates. Compliance costs increase every year without compensation.

    Once the mandatory minutes are enforced providers will be losing more money than ever.

  3. Thank you Mark for your article. Australian Recreational Therapy Association (ARTA), the peak professional body representing Recreational Therapists and leisure and lifestyle staff, working within aged care and health sectors, has been receiving and seeing significant impacts of both our members and non-members from the aged care industry- working as Recreational Therapists and leisure and lifestyle.

    The concerning discussions with professionals within the aged care industry have highlighted that for many, leisure and lifestyle hours have been cut dramatically, and leisure and lifestyle staff have been asked to take on care delivery roles in the replacement of hours, with the expectation to deliver both roles during the shifts (without additional training and support) and in some cases, offered or made redundant.

    ARTA has raised concerns that the loss of such valuable members of what should be a multidisciplinary approach to care, will have huge implications both now and into the near future.

    We know that through tailored meaningful engagement, in the support of people living with dementia and vulnerable Australians, delivered by qualified RT and leisure and lifestyle teams who work as part of a multidisciplinary approach to care delivery assist in improving areas such as falls (engagement, strength-improvement, independence and agitation), psychotropic- chemical restraint, depression, connection to community (reconnection to the wider community through cultural, spiritual, volunteering, social groups, outings).

    We also raise concerns for the care teams, who are being asked to deliver more, outside of their own scope and training/ knowledge base, and worry that consequently, these changes will lead to poorer outcomes for residents, an increase in reportable incidents, not meeting the aged care standards and increased stress across the aged care workforce.

    This discussion needs to be continued, as well as those impacted within the industry also being a voice (albeit hard to do at times) providing feedback to the Aged Care and Quality Safety Commission.

  4. First up, a confession: I was a member of the research team involved in developing the AN-ACC and care minutes requirements. I’m also a registered nurse, with a longstanding interest in public policy that is evidence-based, equitable, sustainable and effective in meeting the needs of citizens that require assistance, and those directly involved in supporting them. As such, I am always interested in how our recommendations get implemented by government and how elements of the sector respond.

    This article raises several points, but overwhelmingly for me it raises the question of ‘why’? Why is it that so much of the sector’s commentary about AN-ACC and the care minutes are focused on the impacts to business models rather than clients’ wellbeing, safety and clinical care?

    It seems that many in the sector continue to have a reactive and iterative rather than proactive and strategic approach to aged care policy development. For example, the introduction of the AN-ACC and care minutes is an explicit acknowledgement that people require residential care due to health and care needs that can no longer be met in the community. Yet I have yet to read of any sector representatives advocating for aged care funding and regulation to be more closely aligned with health. Instead, the general focus is on the costs of providing that care for the aged care provider.

    One option presented to the Royal Commission was to amalgamate health and residential aged care, administered on a regional basis (Prof Kathy Eagar statement RCD.9999.0351.0001), which would support service planning that takes into account local contextual factors and incentivise the development of local solutions. Who knows, maybe the critical shortage of RN capabilities within aged care may not be quite so bad if staff were enabled to work across sector settings? It might also reduce the duplication of quality and safety regulatory functions, ensuring all health needs are appropriately addressed – including allied health – with administrative savings going back into direct care?

    Call me cynical, but I suspect the reason no-one is calling for strategic change is precisely because it might mess with current business models …

  5. Dear Chris, Russell, Renee and Anita,
    Thank you for your comments and a good spread of views. If I can take each one at a time. Firstly, Chris, the fact that parts of the service for people in care has been left out needs to be addressed and it is not reasonable for allied health professionals and lifestyle staff to be left out of the mix and this needs to be addressed so they are funded. Russell, I will cover the point of financial stress later. Renee, like the comment that Chris made it lacks logic as to why you would leave out those who are so important to the emotional, physiological and spiritual wellbeing of people.
    Anita, whilst the studies may have been well intended the consequences of this has not advanced the health and wellbeing of people living in aged care.
    It is not because of the so called “business models” but rather providers are “price takers” and must work within the resources allocated to them by the government. Therefore, it is the government that is fixated on money and what they can afford. Unfortunately, what has been handed to them by the way of minutes of care was not a holistic approach (even if the intention might have been one) and now they are running with a flawed system which in the end the people who are receiving care and services are suffering the consequences. In terms of the health and aged care system becoming one (which I think is where we should be) then you enter the world of Federal and State governments and politics. The question is then – why do these two groups not work for the benefit of the people? The answer might best be described by Groucho Marx’s famous quote about politics – “Politics is the art of looking for trouble, finding it everywhere, diagnosing it incorrectly and applying the wrong remedies”. Anita, you are right to be a cynic. Hopefully, one day we will work on models of care rather than minutes and numbers and dollars.
    Finally, Russell the fact that real funding of over 60% has been stripped out of the sector over the past 20 years has led us to where we are today. A house built on sand as the waves slowly wash away the foundations after years of neglect. We can only hope the house will be built on solid ground one day in the future.

  6. There’s no mystery about why the focus is on business models….that’s what happens when your business sells care as a commodity (Yes, NFPs, you too. All that altruism doesn’t come cheap)
    It’s difficult to believe the creators of AN-ACC (and ACFI, and RCS…) didn’t realise the more complex the system, the more rorting opportunities it presents. Well before this latest funding debacle was even implemented, all the usual suspects were already out looking for loopholes and devising ‘maximisation’ strategies to sell us. Who would have thought…?
    Even more difficult to swallow is that anyone genuinely believed that counting the minutes people spend at work has any relevance to the quality of that work. Surely one of those clever clogs has seen eight council workers patching a single pot hole ?
    It’s misguided and naive to assert the system is an acknowledgement of people’s health and care needs…if anyone actually gave a tinker’s cuss about our seniors, aged care would be part of the health system and we wouldn’t be in this mess.

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