The devaluation of nursing in aged care
1997: new funding model, new philosophy, prescient predictions and a Senate Commitee ignored
A 160 page workforce submission in February 2020 by Counsel Assisting includes an account of the foundations for the deskilling of aged care. It is a story of a change in government funding accompanied by a new residential care philosophy, prescient predictions by nursing organisations and a government apparently deaf to the warning of a Senate Committee.
A new funding formula
The Aged Care Bill 1997 contained a fundamental change in funding arrangements. Until then nursing homes had to allocate a portion of their funding (the Care Aggregated Module CAM) to expenditure on direct care staff and duties. Since the Aged Care Act providers have received a single untied payment for each resident based initially on the Resident Classification Scale (RCS) and now the Aged Care Funding Instrument (ACFI) (P. Rozen QC, Submission para.122).
A philosophy of residential care
University of Wollongong researchers have examined the accompanying policy change which “sought to reframe … residential care as being people’s ‘homes’ and a move away from the institutional model of care” (Submission para.110). At the same time, home care began an ascendancy leading to an upward trend in resident dependency. This in turn calls for more clinical skills.
Unhelpful objective
The Aged Care Act requires providers to “maintain an adequate number of appropriately skilled staff…” (section 54(1)(b)) but the terms “adequate” and “appropriate” are not defined.
Prescient predictions
The Aged Care Bill 1997 was referred to the Senate Community Affairs Reference Committee for examination. Among submissions warning of adverse consequences were those from the NSW College of Nursing and the NSW Nurses’ Association.
“Without those terms being defined we simply cannot guarantee the safety and high standard quality care that is dictated by [residents’] needs”
NSW College of Nursing submission, Senate Community Affairs References Committee, ‘Report on Funding of Aged Care Institutions’, 1997, para. 4.25 (p.58)
[that under the proposed reforms] “nursing staff numbers, skills and the level of experience and expertise will be systematically reduced, that non-nursing staff will be forced to carry the role of nurses, and that, in the end care for residents will suffer”
NSW Nurses’ Association submission, Senate Community Affairs References Committee, 1997, para. 4.27 (p.59)
Senate Committee warning
The Senate Committee concluded that the Aged Care Bill provisions had the potential to compromise the standards of care in nursing homes and recommended that providers continue to be required to allocate a set proportion of their funding to be spent on nursing and personal care. Another recommendation was that the accreditation agency monitor the nurse:resident ratio in homes through a transparent reporting procedure which would signal significant changes (Senate Committee Report para. 4.48 and recommendations 18 and 20).
Warning ignored
The Howard government did not accept the Committee’s report. The response was delivered in the Senate on 2 December, 1997 by the Parliamentary Secretary to the Treasurer, Senator Ian Campbell who said:
“The Senate passed the Aged Care Bill on 27 June 1997 which then received the Royal Assent on 7 July 1997. The Government does not intend to respond further to this report” (Quoted in P. Rozen QC, Submission 21 February 2020, para. 129).
The devaluation of nursing
Between 2003 and 2016, RNs as a proportion of the aged care workforce declined from 21% to 15% and the proportion of ENs declined from 14% to 9%. Allied health professionals declined from 7.6% to 4%. Personal carers increased from 57% to 72%. (Submission, paras. 42-43). Between 2005 and 2016, the proportion of residents with high care needs increased from 63% to 92%.
As Counsel Assisting stated, the thousands of submissions complaining about sub-standard care is hardly surprising (Submission, para. 44).