Not far enough: budget won’t fix aged care’s nursing problem

The Federal Government’s $17.7 billion of funding to the aged care sector is a significant start to improving outcomes for aged Australians, but it does not enough go far enough to solve the problems in aged care which are deep and cultural. The problems are so big that it will require more than just money but careful planning and a determination by all stakeholders to solve the problems.

The Federal Budget revealed the sector will receive $17.7 billion over five years, after the Royal Commission into Aged Care Quality and Safety estimated one-in-three people living in aged care in Australia experiences neglect, physical or emotional abuse.

In terms of shortfalls, the Royal Commission into Aged Care Quality and Safety suggested the sector needs an injection of $10 billion a year, and that the Budget falls short of allocating that amount. The implication of this can be seen in some of the targets: for example, the reduction in the home care waiting list which the government has targeted to reduce by 80,000 over the next two years. However, that is not likely given that the Royal Commission found that, as of June 2020, almost 103,000 older people were waiting for a package.

Other Budget measures include staffing requirements for residential care, where every aged care resident will receive three hours and 20 minutes of care a day. Of that, at least 40 minutes will need to be spent with a registered nurse. From July next year, at least one registered nurse will need to be on shift at every aged care facility, for a minimum of 16 hours a day. But the Royal Commission recommended a nurse be on site 24 hours a day to ensure a better standard of safety and care. Again, the Government has not responded to a key recommendation. 

While the Federal Government can see that more staffing is required for best practice aged care, it should have gone further and mandated minimum staffing levels in aged care homes right now, and insisted on a registered nurse on-site 24 hours a day in all aged care facilities.

We also need to draw more skilled workers to the sector. The Royal Commission found that there are simply not enough skilled workers, particularly nurses, to care for the nation’s aged. The mix of staff who provide aged care is often not matched to the needs of older people. Along with inadequate staffing levels and a lack of skills and training, these are the principal causes of substandard care.

The Budget does not address the need for more nurses to work in aged care. What we have seen in Australia is a gradual decline in the number of nurses working in the sector and, with that, the quality of medical services the aged receive. The Royal Commission found that registered nurses comprised 21 per cent of the residential direct care workforce in 2003, but by 2016, this had dropped to around 15 per cent. The proportion of enrolled nurses also dropped, to 10 per cent from 13 per cent. The Budget funding will not reverse this trend as it does not create clear enough career pathways for nurses.

The Government will provide $216.7 million over three years to upskill staff including making specialist aged care nursing scholarships available. This will also fund a retention bonus of $3700 for nurses who work for the same aged care provider for 12 months. But with so many nurses having left the sector or choosing to work in other healthcare scenarios with more rewarding workplaces, this will not lure them back.

While it is clearly a good thing to have extra funding for staff, it is still not clear where the extra staff will come from, particularly as COVID-19 continues to disrupt the flow of people into Australia. It is also not clear if the $3,700 one-off payment for nurses staying in aged care for at least a year will actually help keep them in the sector – especially as the sector as a whole is not just underpaid but undervalued as well. Many registered nurses are simply not happy working in aged care and no amount of money can fix that.

We need not just more workers, but better trained workers and better managed and governed (including scrutinised) services. The Budget does not do enough to address this urgent need for skills upgrading and training and the auditing of aged care services.

As many as 70 per cent of people in residential aged care could be living with dementia. Dementia, including Alzheimer's disease, overtook lung cancer as the second leading cause of death for men and was the leading cause for women in 2019, according to the ABS. The Royal Commission found that nurses and general practitioners do not have a full understanding of the needs of people living with dementia. It is therefore of crucial importance to train workers to better care for those with dementia.

The Australian Government, the aged care sector and unions must work together to professionalise the personal care workforce. This will require cultural change and improvements to developing career pathways for nurses, training and improving labour conditions for nurses – and even more funding.

Professor Joanne Travaglia is a medical sociologist with a background in health services research, management and leadership. She is Professor of the Master of Health Services Management, Director of the Centre for Health Services Management, and Discipline Lead (Health Services Management) in the Faculty of Health, UTS.