(Image: AAP/Joel Carrett)

With Labor committing to minimum staffing levels in aged cared and the royal commission into the industry being encouraged to mandate minimum levels, the biggest challenge in aged care is yet to be faced.

Anthony Albanese committed Labor to “minimum staffing levels in residential aged care” in a recent speech, after appearing to skirt the issue last year. He had already committed to implementing all the recommendations of the aged care royal commission. In their interim report last year, the commissioners noted “our final report will give close consideration to options to ensure staffing levels, and the mix of staffing, are sufficient to ensure quality and safe care”.

Counsel assisting the commission have submitted a 160-page paper explaining the history of the issue and detailing the case for recommending the commission endorse minimum staffing levels sufficient that facilities reach a care standard based on US guidelines.

Minimum staffing levels is an issue that’s been around for nearly a quarter of a century. In 1997, nursing groups presciently warned the Senate committee examining the Howard government’s aged care bill that it should not abolish requirements that aged care providers dedicate a specific proportion of taxpayer funding to staffing.

The Howard government ignored both the committee’s recommendation and widespread warnings that this would lead to a decline in staff levels and a reduction in staff skills — in particular by reducing the number of registered nurses working in the sector.

The debate has continued ever since. On the one side are aged care workers, unions and families who argue that, with the shift to greater home care, people are arriving in residential care with much more complex needs than previously. This is at the same time that private sector providers have cut the number of nurses working in the sector (something no one disputes — the proportion of nurses in aged care has fallen from around 36% in 2003 to less than one quarter now) and reduced staffing.

On the other side is the industry and the Coalition, which have argued that the shift toward aged care facilities being more like homes and less like institutions has necessitated a change in staffing. They say providers need “flexibility” to have the right mix of staff for their changing client needs, and that there’s no evidence that minimum staff levels improve care.

The current federal regulatory requirement — Queensland and Victoria have their own standards for public facilities — is merely that an appropriate staffing level is maintained by providers to meet accreditation standards. This is a “co-regulatory” approach in which the regulator merely ordains the outcome, as nebulous as that is, while leaving it up to the regulated to determine how they produce it. The result has been clear for years, and it’s demonstrated even more vividly in the failings of private aged care providers in the pandemic.

But providers have a point when they argue there’s little hard evidence about the link between minimum staffing and better care — because there’s been so little measurement of it.

In a paper prepared at the request of the royal commission, a team led by Professor Kathy Eagar found little systematically collected data from around the world. Counsel assisting looked at evidence provided to the commission by sector experts and found solid evidence from overseas of links between higher staffing levels (especially higher nurse levels) and better outcomes in continence, falls, wound management and nutrition.

Eagar and colleagues recommended that the staffing levels framework used by the US Centers for Medicare and Medicaid Services (CMS) be applied to Australia. This is the system that forms the basis of counsel assisting’s submission.

The US framework yields a star rating — one or two stars is unacceptable, three is OK, four is good, five is best practice. Applying that system to Australia, more than 57% of Australian aged care facilities get only one or two stars; 27% manage three stars, and only about 15% get four or five stars.

But Eager’s team also provides an indication of what using this system would entail. Raising all Australian facilities to a three-star staffing standard — acceptable — will require a 20% increase in the entire workforce. Raising them to a four-star level would require an extra 37%. Five-star staffing would require a 50% bigger workforce.

Remember this is already a sector that struggles to retain staff and will, according to the Productivity Commission’s 2011 report, need to double in size to nearly 1 million workers by 2050 to meet the needs of an ageing Australia.

Where will an extra 20% of aged care workers come from — and an extra 20% with greater skills to deliver better outcomes in continence, falls, wounds management and palliative care?

Workforce is the intractable issue at the heart of aged care and seems to have resisted serial efforts by governments to address it. The de facto solution to date has been to rely on temporary migrant workers to fill the increasing gaps. The alternative is a two-star aged care system for most of the people forced to use it.