Yvonne Chaperon - Australian Nursing Federation
21 December 2012
Ms Kerrie Westcott
Director
Legislation Section
Transition Branch
Ageing and Aged Care Division
MDP 550
GPO Box 9848
Canberra ACT 2601
Dear Ms Westcott,
Please find attached the Australian Nursing Federation (ANF) Federal Office submission for the
Department of Health and Ageing consultation in relation to Implementing the Living Longer
Living Better aged care reform package Proposed Changes to the Aged Care Act 1997 and
Related Legislation.
Please don't hesitate to contact Leigh Hubbard, Acting Industrial Officer on 03 96028503 or
leigh@anf.org.au if you have any further questions.
Yours sincerely
Yvonne Chaperon
Assistant Federal Secretary
Overview
The Australian Nursing Federation (ANF) welcomes the opportunity to comment on the draft
Overview of proposed changes to the Aged Care Act 1997 and related legislation.
The ANF represents over 220,000 nurses, midwives and assistants in nursing around Australia.
More than 35,000 members are employed in aged care around Australia, with around 75% of
these members being Registered Nurses (RNs) and Enrolled Nurses (ENs), primarily in
residential aged care.
As the biggest union in aged care, representing those providing nursing care, we want to ensure
that any change to the legislation does not undermine the already minimal requirements under
the Aged Care Act 1997 and the Aged Care Principles in respect to staffing levels and skill mix.
While the ANF has publicly welcomed the direction of the changes announced in the Living
Longer Living Better reform package In April 2012, we remain especially concerned about the
quality of care provided to older Australians.
The ANF remains committed to campaigning for:

Better funding for wages for aged care nursing staff in order to attract (and retain) more
RNs and ENs to the sector. This matter was partly addressed in the workforce section of


the LLLB package and we are hopeful that the Aged Care Financing Authority will
further review and improve the wages of care staff.
Better staffing and skill mix in aged care, both in terms of raw staffing numbers and the
skill mix that applies to the resident care needs profile in a facility at any time. We are
especially concerned that there is insufficient guidance for the providers and the ACSAA
(soon to be the AACQA) as to what constitutes "an adequate number of appropriately
skilled staff to ensure that the care needs of care recipients are met" (s. 54-1 of the Aged
care Act 1997).
Regulation/licencing of, and national benchmark training for, Personal Care Workers and
Assistants In Nursing in aged care, but especially in residential aged care. We share the
concerns of many stakeholders in the industry as expressed to the Productivity
Commission in 2011 about the poor quality of the Certificate III and IV training provided
to new entrants to the industry. In addition there are no minimum training requirements
with the 2007 NILS census and survey showing that 25% of the care workforce had no
qualification at all. There is now a need to ensure that every worker has a qualification.
We believe this area needs considerable improvement. However, in addition we continue
to press for the registration of carers (AI N/PCW however titled) who would benefit from
having a clear scope of practice vis a vis RNs and ENs.
Part 1: Residential care - Improving choice in relation to types of
care and services
Quality Care
The quality of the personal and clinical nursing care provided to aged care residents is a product
of both how many staff are rostered within each residential aged care facility and, perhaps more
importantly, the skill mix among those staff.
Over the last 15 years we have witnessed a significant change in the numbers of RNs and ENs
engaged in residential aged care. The massive decline in both the percentage and FTE of RNs
and ENs as a proportion of the workforce has occurred despite the exponential increase in the
admission age and frailty of residents. We know that the move to 'later and frailer' entry into
residential care means that around 70% of the admissions to residential aged care have high care
needs and 55% are aged 85 years or more. It would be logical to assume that the composition of
the workforce would reflect this shift and that there would be an increased number of more
highly skilled nurses. In fact the opposite trend has occurred. The latest NILS Aged Care
Workforce Survey 2012 Draft Report confirms this dramatic change:
FTE Equivalent direct care employees in the residential aged care workforce
Occupation
2003
2007
2012
RN
21.4
16.8
14.7
EN
14.4
12.5
11.6
PCNPCW/AIN
26.5
64.1
68.2
Occupation
2003
2007
2012
Total FTE
76,006
78,849
94,823
The ANF remains concerned that over the last decade as acuity has increased dramatically there
has been a corresponding decline in the proportion of RNs and ENs in the residential aged care
workforce from 35.8% of total FTE to 26.3% of total FTE.
In our view the changing skill mix is a factor in the capacity of the sector to deliver quality care
to increasingly sick and frail residents. With the increasing employment of AIN/PCW into the
aged care sector it is Imperative that their level of education is delivered in the VET sector under
national benchmark training so all AI N/PCW have the same qualification so sound quality care
is delivered. However, this has not occurred. Recent national and international literature reviews
have substantiated the need for registered nurses as a means to providing quality care irrespective
of the sector the patient/resident is being cared for. It is therefore important to consider the
staffing level and skill mix to provide this care.
We do know that the more the staffing profile changes and the RN/EN component of the
workforce diminishes the more stress, mistakes and challenges aged care nurses face in
delivering quality care. In this regard please see the survey and study over three years conducted
by the University of Melbourne 2008, 2009 and 2010 [Sargent, L, Harley, B. and Allen, B.]
Working in aged care: Medication practices, workplace aggression, and employee and resident
outcomes, Reports prepared for the Australian Nursing Federation (Victorian Branch), The
University of Melbourne and referred to in the submission of the ANF (Victorian Branch).
While this has been occurring the only obligations imposed on providers in respect to
maintaining the quality of services are:
1. Aged Care Act 1997
s54 1 Responsibilities of approved providers
(1) The responsibilities of an approved provider in relation to the quality of the 'aged care that
the approved provider provides are as follows:
to provide such care and services as are specified in the Quality of Care Principles in respect of
aged care of the type in question;
to maintain an adequate number of appropriately skilled staff to ensure that the care needs of care
recipients are met;
to provide care and services of a quality that is consistent with any rights and responsibilities of
care recipients that are specified in the User Rights Principles for the purposes of paragraph 56 1
(1),56 2(i) or 56 30);
If the care is provided through a residential care service-to comply with the Accreditation
Standards made under section 54 2;
As indicated above we hold the view that the framework for assessing "adequate number of
appropriately skilled staff' in the context of maintaining an acceptable quality of care for
residents is vague and uncertain. Any change to the legislation should not have the effect of
undermining these already minimal requirements.
2. The requirement in the Aged Care Act is supplemented by the Aged Care Principles 1997. The
primary document Is the Quality of Care Principles 1997 which provide in clause 18 that certain
care and services to residents must be as prescribed in Schedule
1. However, paragraph 18.6(3) provides that the nursing services specified in Part 3 of Schedule
1 (being those required to be delivered by a Registered Nurse) "are required only for" those
residents defined as "high care".
Clause 18.6(4) also provides that for residents defined as high care after a certain date "if initial
and on-going assessment, planning and management of care for residents (nursing services as
described in Item 3.8 of Part 3 of Schedule 1) is required, it must be carried out by a registered
nurse."
We assume that the Aged Care Standards and Accreditation Agency has developed standards in
relation to the practical meaning of ensuring that "an adequate number of appropriately skilled
staff to ensure that the care needs of care recipients are met." However, if such standards exist
they are not transparent or agreed with industry stakeholders. This means that interpretation and
implementation of the requirement sin relation to staffing are subjective and sometimes
inconsistent. The legislation should require ACSAA (or AACQA) to develop clear and
transparent standards for staffing, including both numbers of staff and skill mix, in consultation
with industry stakeholders.
Discussion
ANF is aware of and is participating in the consultation over the review of specified care and
services to be provided to high and low care recipients. We welcome further involvement in that
review.
In our submission the proposal (p12, first paragraph) that apart from an exception in respect to
respite care "the concepts of high and low level residential care will also be removed from the
Act and the Principles ... " needs to be treated cautiously in respect to the nursing and other care
services required to be provided to residents currently classified as high care.
The ANF advocates that the Principles be amended to remove clause 18.3 and the restriction that
the Schedule 1, Part 3 services only applying to high care residents. In other words we would
welcome an amendment that requires the services in Part 3 of Schedule 1 to be provided to all
residents who need them regardless of their ACAS or ACFI status.
The ANF submits that the removal of the distinction between high and low care must be
accompanied by a new model of care that addresses and responds to the care needs of each
resident. The ANF has advocated that both the legislation and the Principles mandate a staffing
and skill mix matrix that specifies more clearly the approximate RN, EN and Personal Care time
that is required by a resident or group of residents with particular care needs. We believe this is
more appropriate than a list of 'tasks' as currently contained in the Aged Care Principles. Such a
list cannot take into account the need for observation and monitoring of a resident's condition
and their change in condition, which routinely occurs when RNs and ENs are employed in
sufficient numbers in a facility. However, until such a matrix is available and agreed across the
industry it is certainly better to have a list of tasks than nothing at all.
In relation to each resident (and, in each facility, the sum of every residents care needs) the
provider should have an obligation to provide sufficient staff of the appropriate skill mix to meet
the clearly determined hours and minutes of care to be provided by each category of staff (RN,
EN, personal carer, allied health etc). These staff needs should be capable of being determined
easily and be transparently available so that all stakeholders - providers, staff, residents, families
and the MCQA - can confirm that the required number of appropriately skilled staff are on the
roster for any given shift. The ANF has commenced a project, funded by the Commonwealth, to
design such a matrix.
Choice in relation to amenities and services
Page 12 of the Overview document states that "the current list of services is currently being
reviewed, in consultation with stakeholders to support and Single set of requirements". ANF is a
party to this consultation process.
On the same page, the discussion about 'amenities and services' also refers to the 'list of specified
care and services'. It also describes that "approved providers of residential care will continue to
be able to offer care on a dedicated 'extra service basis'," There needs to be very clear definition
of "care" and "service", and this sentence concerns ANF in its use of both terms in relation to
'extra service'. One consumer body we consult gave an example of a facility where the resident
was told they would need to pay for the 'expensive' dressing if they wanted the dressing change
more often. The implication was that the provider wasn't charging for the 'care' I.e. the nurse or
AIN/PCW performing the care, but could charge for the 'expensive' dressing being used presumably because this perceived as a 'request' not a clinical need. In another example a
resident in a low care facility was not being provided with the catheter bag that worked best for
them (and which was used at the hospital when the catheter was first inserted). Again, that
resident was told that they must pay personally for the more 'expensive' catheter bag. There
needs to be very clear description of the difference between 'care' and 'service' if such arguments
already occur.
We believe that 'care' in the clinical sense of that word, must include any equipment, therapies,
processes, dressings or medications which is ancillary to or associated with that care. These
items should not be the subject of 'extra services'. This care and these items should not be a
matter of choice but part of basic and uniform standard of care provided to all residents
regardless of their capacity to pay. Just as provision of a toothbrush and toothpaste or showering
every day should not be an 'extra service' nor should the quality of the wound dressing or the
length of a physiotherapy session.
The ANF has considerable concerns in respect to what constitutes additional amenities and
services. There will be the temptation for some providers to move basic amenities and services
into the 'extra services' category. We have seen this in the past with items from bananas to
window coverings. Providing 'choice' should not lead to a two tier system in which the basic
amenities, services and care are below a standard which most older Australians and their families
would expect to receive.
Part 2: Residential care - Fairer means testing for care fees
The ANF generally supports the proposals in respect to restructuring of fees based on a greater
contribution to accommodation and care costs from those older Australians who can afford to do
so. However, we have supported such an approach only on the basis that:


Low income older Australians and those with modest income/assets are protected from
additional charges or subsidy reduction; and
Additional monies raised are used to improve staffing and accommodation standards to
improve care and the quality of life for residents and those receiving care in the
community care.
We remain concerned at the potential impact of the proposed calculation at Attachment A in
respect to care subsidy reduction. The point at which the Government pays the full subsidy
appears to be set at a quite low level (p. 17), especially in respect to assets ($40,500). However,
we accept that that the costing of the reform package and forward projections concerning the cost
of aged care has been based on estimated capacity to pay by recipients of aged care services. We
also acknowledge the annual and lifetime caps on care subsidy reduction. For these reasons we
do not propose any alternative thresholds but, together with other stakeholders, we will monitor
the impact of the calculation closely.
Part 3 - residential care - Flexibility and choice in paying for
accommodation costs
The ANF is in general agreement with the proposals for changes to the legislation.
We note that a provider is able to charge interest where a care recipient does not pay the periodic
accommodation payment on time. In this regard, we believe the legislation should specify that
the interest charged (including that deducted from lump sum accommodation payments) should
be capped at no more than 60% of the statutory interest rate.
Part 4 and 5 - Home care
ANF supports the proposed framework for legislative amendments in respect to both the
restructuring of existing packages and the means testing in respect to those packages.
In particular we support the introduction of the dementia supplement, but believe that there
should be a requirement in the Act or Principles that providers be able to demonstrate, if required
by audit, that the dementia supplement has been utilised to "provide additional and more
appropriate care, to care recipients with dementia." (p31)
ANF notes that the Secretary may make a hardship determination where a care recipient is
unable to pay part or all of the basic daily care fee. However, we are unclear about the level of
information or assistance that the provider needs to make available in respect to the possibility of
applying for a hardship determination. This should be a requirement upon the provider and
included in the legislation. In addition, there should be an appeal mechanism against an adverse
finding in a hardship application.
Part 6 - Improved governance
ANF supports the proposed changes in respect to the introduction of an Aged Care Pricing
Authority and the new Australian Aged Care Quality Agency.
We welcome that the new Quality Agency will be "the sole agency that providers will deal with".
Our only comment in this regard is that there needs to be closer integration between information
and activities of the Aged Care Complaints Scheme and the Quality Agency. In this regard we
suggest that the new Agency should also have responsibility for the Complaints Scheme,
including investigations and reporting to the Minister and to Parliament in relation to the
categories of complaints, outcomes of investigations and actions taken (whether forced or
voluntary).
We also note and welcome the proposed review of the impact of the reforms and the legislation.
We note that those undertaking the review must consult a broad range of people. However,
unions and professional bodies are not specifically included and we request that those
representing the workforce be referred to.
Part 7: Other proposed consequential or administrative changes
The ANF supports the proposals in Part 7. In respect to Administrators and Advisors the ANF
supports the need for such appointments to possess requisite skills and experience. However, we
remain concerned about the cost of such expert appointments. We believe that there should be a
schedule of maximum fees that is balanced and appropriate. given the need for expert
administration and advice on the one hand against the often precarious financial situation of the
provider on the other (which has sometimes triggered the sanctions in the first place).
Conclusion
The Australian Nursing Federation welcomes the opportunity to provide comment in relation to
the proposed amendment of the Aged Care Act 1997, and acknowledge that any change to the
current Aged Care Act will result in consequential amendment to the Quality of Aged Care
Principles 1997.
ANF has positively supported the thrust of the aged care reform package. We support the end of
the distinction between high and low care and provision of care and accommodation based on
assessed need. We support the focus on ensuring that older Australians can stay in their homes
longer and that those who can afford to contribute to accommodation and care costs should do
so.
However, Our concern continues to be that:




Those with no or modest private income or assets continue to be fully subsidised
Additional funds generated by the reforms are invested in better care and accommodation
and not in higher per bed profits for private providers
That all residents receive appropriate nursing care at all times
Staffing and skill mix is improved in residential care and that the trend towards a less
skilled workforce (despite a progressively older and frailer resident population) is
reversed

Expansion of extra services provision does not establish a two tier system and that 'basic'
services' does not mean sub-standard services
It is important that the amendments to the Act and Principles ensure that these concerns are not
realised.