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Chapter 6: Ensuring quality of care

4.1 A large number of organisations during the inquiry expressed concerns that the aged care reforms have the potential to compromise the standards of care in aged care facilities. [1] The NSW College of Nursing told the Committee that if the Bill passes in its current form `we cannot guarantee that residents of aged care facilities...will receive care of the standard that they require or that they will be safe'. [2] The Australian Nursing Federation (ANF) stated that the Bill `does little to reassure the... Federation that it directs itself to preserving quality of care to the elderly residents in nursing homes and hostels'. [3]

 
Current arrangements

4.2 The present arrangements for ensuring quality of care in nursing homes and hostels involve assessment of compliance by providers with defined outcome standards. This involves Standards Monitoring Teams visiting homes and assessing services against agreed minimum standards (Outcome Standards). If a home is seen to be not performing, the Standards Monitoring Team will present a report to the home requiring action against particular standards. If the home continues to breach the standards the Government has the power to stop funding, either in part or in full. Nursing homes are also required to acquit a portion of their funding called the Care Aggregated Module (CAM) against expenditure on direct care staff and duties. CAM's intention was to give nursing homes more flexibility in setting staffing levels. [4]

 

Proposed arrangements

4.3 Under the Reform Package it is proposed to introduce from 1 January 1998 a new quality assurance system based on accreditation. The Department of Health and Family Services (DHFS) stated that the aim of the accreditation based system is to `promote continuous improvement and higher levels of quality'. [5] The Department noted that the new system will balance the enforcement of minimum standards with recognition and encouragement of higher quality in aged care facilities. [6] DHFS also noted that it `reflects a shift from sole Government responsibility to ensure quality to a shared responsibility for ensuring quality among providers, consumer representatives and Government'. [7]

4.4 The accreditation arrangements will be overseen by an independent Aged Care Standards Agency, the board of which will comprise individuals with a representative range of aged care and management experience. The role of the Agency will be to promote quality management within facilities, oversee the accreditation process, and identify any facilities not meeting minimum requirements. DHFS, in association with the Agency, will have the power to take action against facilities which are substandard and whose operators have themselves taken inadequate action to achieve a sustained improvement in the situation. [8]

4.5 Under the reforms it is also proposed that nursing home operators will receive a single non-acquitted payment for each resident instead of the existing funding structure based on CAM, Standard Aggregated Module (SAM) and Other Cost Reimbursed Expenditure (OCRE). As noted above, CAM provides funding to meet the costs of nursing and personal care (essentially nursing and therapy staff wages). SAM provides funding to meet such costs as food, electricity, building maintenance and the salaries of the administrators and domestic staff, while OCRE provides cost reimbursement for staff superannuation, workers' compensation, payroll tax and long service leave. [9]

Becoming accredited

4.6 To become accredited all residential aged care services will be assessed against an agreed set of accreditation standards. The accreditation standards, which are set out in the draft Principles (Schedule 1), cover four categories health and personal care, resident lifestyle, physical environment and safe practice and management systems, staffing and organisational development. The first three categories largely cover standards addressed in the current outcome standards. The fourth establishes new standards relating to management systems, including the employment of skilled staff. [10]

Transitional period (to December 2000)

4.7 During the transition period services will continue to be assessed by DHFS (to December 1997). After January 1998 those services not yet accredited will be assessed against their capacity to meet the residential care standards (that is, the first three categories of the accreditation standards) by the Aged Care Standards Agency. Services will be identified against risk factors, such as complaints, to ensure that they meet present requirements. Regulatory action will be taken against those facilities identified as not complying with those standards. [11]

4.8 Following a transition period of three years from 1 January 1998 only accredited services will be eligible to receive Commonwealth funding to provide residential care services. DHFS noted that `full details' of the new arrangements are being developed in consultation with stakeholder groups. [12]

Resident Classification Scale

4.9 Under the reforms, the Resident Classification Scale (RCS), formerly called the Single Classification Instrument, is designed to assess the care needs of residents irrespective of whether they reside in a nursing home or a hostel. The funding rates attached to the RCS were released on 26 May 1997. [13]

4.10 The aim of the RCS is to ensure that residents are funded according to their needs no matter what kind of facility they are in, and will allow facilities to meet residents' care needs as they change over time. One of the purposes of the new Instrument is to ensure better funding for dementia care. DHFS noted that the new RCS `brings better recognition and weighting of dementia care needs. Together with the new funding scale, this means funding for hostel residents with identified dementia care needs increases by over 30 per cent on average'. [14]

4.11 The existing nursing home Resident Classification Instrument and hostel Personal Care Assessment Instrument will be phased out gradually over a 12 month period in nursing homes, and over a six month period in hostels. All residents entering care after the commencement of the new arrangements will have their care needs assessed using the new Instrument. The RCS is linked to a new single scale of subsidy levels that will apply across both nursing homes and hostels. The Minister announced on 26 May 1997 that there will be eight funding categories reflecting the range of dependency levels. [15]

 

Issues

4.12 A number of issues were raised in relation to ensuring that the quality of care is maintained in nursing homes under the new arrangements and these are discussed below.

Abolition of CAM funding

4.13 Many organisations, including the ANF and NSW Nurses Association, expressed concern at the proposed abolition of CAM funding and the adoption of a single non-acquittable payment system. [16] The ANF and the NSW Nurses Association stated that the use of CAM ensured that public money provided to nursing homes by the Government was used for its intended purpose `this meant that providers were accountable for funds and, importantly, it meant that this money was spent on the provision of care for residents. The system was transparent and allowed the community to have some certainty about staffing levels in nursing homes'. [17]

4.14 The NSW Nurses Association argued that:

With the CAM system of assessing needs and delineating whether registered nursing hours are needed or enrolled or assistant nursing hours are needed, the measured hours guaranteed care levels [which meant] that 97 per cent the 1450 nursing homes are operating at a good level, a great level, and are providing the type and level of nursing care that is needed. [18]

4.15 The NSW Nurses Association further noted that under the current system:

There is an integrated system of funding, which delivers specific standards of care and, with that, skilled nursing staff and other trained allied health staff....The RCI gives us the funding at a guaranteed level, guarantees thereby the care level and the acquittal processthe auditing processgives us certainty. It is definitely a circle. If the system of the quality circle single-payment is dismantled, then we believe we can give no guarantee as nurses...for that standard to be maintained. [19]

4.16 The ANF argued that under the proposed system there is a real danger that proprietors will attempt to maximise their profits by deskilling their workforce and thereby compromising the care given to residents. [20]

4.17 The ANF and the NSW Nurses Association noted that the collapsing of specific funding for skilled workers, particularly trained nurses, will have a detrimental impact on skilled employment in the nursing sector. The ANF and NSW Nurses Association argued that employers have already foreshadowed their intention to reduce and retrench staff as a consequence of the introduction of the new arrangements. The ANF also noted the `great uncertainty' amongst the workforce as a consequence of the proposed changes. [21]

4.18 The Gregory report noted that a system of non-acquittable grants is attractive as a response to the rigidities and administrative costs imposed by the requirement of the current funding system that separate CAM and SAM expenditure and demand an acquittal of CAM funding. The system would allow proprietors to keep as a profit, or surplus, savings they can make on the cost of nursing and personal care staff and so provide a strong incentive for cost savings in that area. [22]

4.19 The Gregory report noted, however, that this option has potential disadvantages, especially relating to the ability of the funding system to ensure proper levels of care. The report noted that neither the current standards monitoring system, nor any alternatives considered, would be able to prevent the diversion of funding from nursing and personal care to profit. [23]

4.20 DHFS argued that the removal of CAM acquittal would not undermine the quality of care in nursing homes. The Department noted that CAM acquittal `occurs some three or so years on average after the money is spent'. [24] DHFS also noted that there is not a direct correlation between CAM expenditure and the quality of care that is provided `it goes far more to the attitudes and approach of the staff than as to whether you actually spend 100 per cent of CAM'. [25]

4.21 The Committee considers that any system that claims to be concerned about the quality of care in nursing homes must ensure that public money provided for nursing care is spent for this purpose. The Committee therefore considers that funding provided to meet the costs of nursing and personal care should continue to be acquitted against expenditure.

Appropriately qualified nursing staff

4.22 Many concerns were expressed that the proposed reforms would be unable to ensure adequate levels of care will be delivered by appropriately skilled and trained staff and that neither the Bill nor the Principles contain sufficient assurance on this matter. [26]

4.23 The importance of maintaining highly qualified nursing staff in nursing homes was underlined by the NSW College of Nursing who stated that there are increasing numbers of people being admitted to nursing homes with severe multisystem disorders and illnesses that require the equivalent of services that are provided by acute medical units in teaching hospitals. [27] The College estimated that about 30 to 40 per cent of patients in nursing homes are acute care patients. [28]

4.24 As a result of comments provided on the exposure draft, the Aged Care Bill as introduced (Division 54) was amended to include responsibilities for approved providers to:

• maintain an adequate number of appropriately skilled staff to ensure that the needs of care recipients are met; and
• provide care and services of a quality that is consistent with any rights and responsibilities of care recipients that may be set out in User Rights Principles. [29]

4.25 The NSW College of Nursing stated, however, that it was of concern that the Bill made so much use of the words `adequate' and `appropriate' in relation to the use of qualified staff in nursing homes but with no definition of these terms. The College added:

Without those terms being defined we simply cannot guarantee the safety and high standard quality care that is dictated by their needs, because not only do they require qualified registered nurse care to a great extent ...but it cannot be given without those nurses being employed, and more so, without nurses who also have specialist qualifications in the area. [30]

4.26 The Royal College of Nursing, Australia (RCNA) also noted that, in terms of staffing, the Bill says very little about the kind of care that needs to be given or the kinds of medical illnesses that nurses have to deal with in nursing homes, especially in the area of dementia. [31]

4.27 Other concerns were expressed that increasing numbers of non-nursing trained staff will be required to undertake nursing tasks under the proposed reforms. [32] The ANF and the NSW Nurses Association stated that `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'. [33]

4.28 The NSW Nurses Association noted that the current system stipulates the number of registered nursing hours and the number of other nursing hours required for the care of residents in nursing homes `we would hold grave fears that if the situation was such that the level of regulation of nursing standards was not there, and if it was replaced by an unregulated standard with no statute and regulations attached to the personnel that would replace nurses, nursing homes would be heading for a pretty disastrous time in terms of care standards'. [34]

4.29 The Combined Pensioners and Superannuants Association of NSW (CPSA) suggested that the Aged Care Standards Agency should consider the appropriate ratio of trained staff to the number of residents in nursing homes, as well as monitoring the level of trained staffing levels in nursing homes. In addition, the CPSA suggested that trained staffing ratios to residents become an integral part of accrediting nursing homes. [35]

4.30 The Australian Catholic Health Care Association (ACHCA) stated that in the absence of an acquittal process `the only way Government, consumers and the community will be satisfied that care standards are being performed by appropriately trained staff will be through the accreditation standards and the quality assurance system'. [36]

4.31 DHFS stated that the RCS will indicate in a number of cases where particular functions would have to be performed by a person who is appropriately qualified. The Department added:

The instrument [RCS] cross-refers...to the relevant requirements of State legislation and to relevant requirements in terms of professional standards, best practice, et cetera...In essence, the current requirements of making sure that you meet State requirements and the tasks are performed by appropriately qualified people are continued. There are particular references in the single classification instrument. The bill itself talks about the provision of high quality care. The standards arrangements will continue in the interim...to have a particular focus in the new accreditation arrangements. That will go to the qualifications, experience and capacity of staff to deliver the care that people need. [37]

4.32 The Committee considers that as nursing care is the essence of residential aged care, the reforms need to guarantee that the quality of nursing and other care will be available in nursing homes and that this nursing care will be delivered by appropriately skilled and trained staff. The Committee believes that the accreditation standards and quality assurance system needs to ensure that skilled and trained nursing staff levels are maintained in aged care facilities and that these levels should be monitored by the Aged Care Standards Agency.

Resident Classification Scale

4.33 A number of concerns were expressed during the inquiry in relation to the Resident Classification Scale (formerly referred to as the Single Classification Instrument) especially as regards its application and the funding implications that will arise from its introduction.

4.34 DHFS stated that the RCS `will ensure that care needs are assessed and residents are funded according to their care needs no matter what kind of facility they are in, and will allow facilities to meet residents' care needs as they change over time'. [38] As noted above, there are eight care categories reflecting the range of dependency levels. The care categories are divided into a high and a low level reflecting the existing distinction between nursing homes and hostels. [39]

4.35 ACHCA explained that the RCS is essentially a `resource allocation tool' designed to redistribute a given subsidy poolwhich is the subsidy pool that exists nowto suit the Government's wish to increase funding for dementia care and for high dependency people in hostels `it is of concern to us that that pool is being asked to perform tasks through the single classification instrument in terms of increased funding levels without increased dollars being apportioned'. [40] ACHCA noted that the demand for relevant care will not be achieved unless the RCS as a relative resource allocation tool is supported by the appropriate funds. [41]

4.36 The NSW College of Nursing raised criticisms of the study methodology that led to the development of the RCS arguing that `the results are that the tool is fairly meaningless and we are highly critical of that'. [42] Concerns were also raised that the delay in finalising the Instrument posed problems for providers in terms of training staff in its use and also raised funding implications. [43]

4.37 The Committee regrets that details of the Resident Classification Scale were not available during the Committee's hearings. While the RCS was released on 8 May the funding rates were only announced on 26 May 1997.

Role of the Aged Care Standards Agency

4.38 Evidence to the Committee suggested that ensuring quality of care in nursing homes will be a major challenge for the new Aged Care Standards Agency, to be established from 1 January 1998. [44] As noted above, the Agency will oversee the accreditation arrangements and monitor compliance with these arrangements.

4.39 DHFS stated that an essential role of the Agency will be to promote quality management and the accreditation process to services and assist them through skills development, education, training and other support services. The Agency will also take responsibility for low quality services and work with the Department to ensure such services either improve and reach accreditation requirements or, where necessary, are removed from the system. [45]

4.40 ACHCA noted that the elimination of nursing and personal care funding acquittals in nursing homes will remove considerable regulatory requirements from providers but may lead to some providers cost cutting in the areas of care to the detriment of residents. [46]

4.41 The Australian Pensioners' and Superannuants' Federation (APSF) stated that the success of the accreditation process will be compromised if there is insufficient input from consumer representatives to provide a consumer perspective into policy and management issues. Furthermore, APSF argued that there may be a conflict of interest in the Agency having a role of both encouraging quality assurance and monitoring and applying sanctions. APSF argued that the Agency's role should be to encourage the industry to achieve optimum quality, while the Government should focus on monitoring and applying sanctions where facilities do not meet the required standards. [47]

4.42 Residential Care Rights also noted that there is a strong perception among consumers and their representatives that `a significant focus of the Agency will be the needs of service providers' to the detriment of consumer interests. [48]

4.43 Other evidence suggested, however, that the Agency could fulfil the roles of maintaining quality assurance and monitoring compliance. ACHCA suggested that the Agency needed to be supplied with the necessary investigative powers comparable with other Government agencies that have similar responsibilities for protecting consumers and safeguarding their rights. The ACHCA also argued that the Agency must be established with a Chairperson and Board of Directors with the skills and competence to ensure that the quality of care in residential aged care facilities is protected. [49] The Australian Council of Social Service (ACOSS) argued that the amount of funds committed to the Agency needed to be sufficient to facilitate its work. [50]

4.44 The Committee believes that quality of care needs to be protected and enhanced in aged care facilities. The Committee notes that full details of how the proposed new Aged Care Standards Agency will operate are not available and therefore it is difficult to determine the exact role it will play in monitoring standards of care. The Committee believes, however, that the new Aged Care Standards Agency should play an important role in this regard and needs to have adequate monitoring and enforcement mechanisms in place to ensure industry compliance with care standards and be adequately funded.

Transitional period

4.45 Concerns were expressed during the inquiry at the length of the transitional period (to December 2000) to implement accreditation of aged care facilities.

4.46 The ANF and NSW Nurses Association and the APSF argued that there should be a shorter timeframe for proprietors to achieve accreditation in respect of care standards. The ANF and the NSW Nurses Association argued that this would minimise the potential for the development of `three tiers' of care standards extra services facilities, accredited facilities and non-accredited facilities. [51] The APSF argued that accreditation should be brought forward one year (to 1 January 1999). [52] The ANF also argued that the Government should apply pressure on the industry to ensure that all homes meet accreditation by `declaring what it intends for those which don't measure up within the required time'. [53] The ANF also argued that accreditation should be a requirement of approved provider status.

4.47 DHFS indicated that during the transitional period, services will continue to be assessed and that `there would be no reduction in the level of effort applied to standards monitoring' during this period. [54]

 

Conclusion

4.48 The Committee believes that that the Government's aged care reform proposals have the potential to compromise the standards of care in aged care facilities. The present arrangements for quality of care in nursing homes and hostels has achieved a substantial improvement in residents' quality of care and quality of life. The Committee regrets that the full details of the new quality assurance system based on accreditation is not yet available.

4.49 The Committee also has particular concerns at the proposed abolition of CAM funding and the introduction of a single non-acquittable payment system and the fact that the proposed reform package does not contain adequate provisions to ensure that proper levels of care will be delivered by appropriately skilled and trained staff to residents of aged care facilities.

Recommendation 18: The Committee recommends that nursing homes continue to be required to acquit that proportion of their funding expended on nursing and personal care.

Recommendation 19: The Committee recommends that the accreditation standards and quality assurance system provide for the employment of appropriately skilled and trained nursing staff to ensure that quality of care is maintained in aged care facilities.

Recommendation 20: The Committee recommends that the Aged Care Standards Agency monitor the ratio of trained nursing staff per resident in nursing homes through a transparent reporting procedure which would signal significant change in the ratio.

Recommendation 21: The Committee recommends that the Aged Care Standards Agency be established with the necessary investigative powers to ensure that the quality of care and rights of residents are maintained and protected.

Recommendation 22: The Committee recommends that the Aged Care Standards Agency have monitoring and enforcement mechanisms in place to ensure industry compliance with care standards and be funded to meet those objectives.

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Footnotes

[1] Submission No.34, p.9 (ANF & NSW Nurses Association); Submission No.66 p.13 (CSA); Submission No.24, p.6 (NSW College of Nursing and GeriactionNSW); Submission No.79, p.2 (ACTU); Submission No.68, pp.3-4 (OPC).

[2] Transcript of Evidence, p.121 (NSW College of Nursing).

[3] Submission No.34, p.9 (ANF & NSW Nurses Association).

[4] Submission No.94, pp.48-49 (DHFS); Submission No.58, p.21 (APSF).

[5] Submission No.94, p.49 (DHFS).

[6] DHFS, Additional Information, 22 May 1997, p.5.

[7] Submission No.94, p.49 (DHFS).

[8] Submission No.94, pp.26,49 (DHFS).

[9] Professor R.Gregory, Review of the Structure of Nursing Home Funding Arrangement:Stage 1, August 1993, p.8.

[10] Submission No.94, pp.49-50 (DHFS).

[11] Submission No.94, p.50 (DHFS).

[12] Submission No.94, p.50 (DHFS).

[13] Minister for Family Services, Media Release, `Aged Care Structural Reform Details Announced', 26 May 1997.

[14] Minister for Family Services, Media Release, 26 May 1997, p.2. See also Submission No.94, p.14 (DHFS); DHFS, Additional Information, 22 May 1997, p.3.

[15] Minister for Family Services, Media Release, 26 May 1997. See also Submission No.94, p.14 (DHFS); DHFS, Additional Information, 22 May 1997, p.3.

[16] Submission No.34, p.10 (ANF & NSW Nurses Association); Submission No.82, p.3 (ANF- Victorian Branch); Submission No.85, p.3 (Victorian Nurse Executives Association).

[17] Submission No.34, p.10 (ANF & NSW Nurses Association).

[18] Transcript of Evidence, p.155 (NSW Nurses Association).

[19] Transcript of Evidence, p.153 (NSW Nurses Association).

[20] Submission No.34, p.10 (ANF & NSW Nurses Association).

[21] Submission No.34, p.10 (ANF & NSW Nurses Association).

[22] Gregory, op.cit., p.21.

[23] ibid., pp.32, 79.

[24] Transcript of Evidence, p.286 (DHFS).

[25] Transcript of Evidence, p.287 (DHFS).

[26] Transcript of Evidence, pp.121-22 (NSW College of Nursing/Royal College of Nursing); Transcript of Evidence, p.212 (ACHCA); Submission No.50, p.11 (CPSA of NSW).

[27] Transcript of Evidence, p.120 (NSW College of Nursing).

[28] Transcript of Evidence, p.124 (NSW College of Nursing).

[29] See also Submission No.94 (DHFS), Appendix 1, p.7.

[30] Transcript of Evidence, p.121 (NSW College of Nursing).

[31] Transcript of Evidence, pp.121-22 (RCNA).

[32] Transcript of Evidence, p.166 (NSW Nurses Association); Transcript of Evidence, p.167 (ACTU).

[33] Transcript of Evidence, p.154 (NSW Nurses Association/ANF).

[34] Transcript of Evidence, p.166 (NSW Nurses Association).

[35] Submission No.50, p.11 (CPSA of NSW).

[36] Transcript of Evidence, p.213 (ACHCA).

[37] Transcript of Evidence, p.287 (DHFS).

[38] DHFS, Additional Information, 22 May 1997, p.3.

[39] Minister for Family Services, Media Release, 26 May 1997, pp.2-3. See also DHFS, Additional Information, 22 May 1997, p.3.

[40] Transcript of Evidence, p.212 (ACHCA).

[41] Submission No.38, p.19 (ACHCA).

[42] Transcript of Evidence, p.127 (NSW College of Nursing).

[43] Transcript of Evidence, p.151 (ACA).

[44] Submission No.38, p.19 (ACHCA); Submission No.58, p.22 (APSF).

[45] DHFS, Additional Information, 22 May 1997, p.6.

[46] Submission No.38, p.19 (ACHCA).

[47] Submission No.58, p.22 (APSF).

[48] Submission No.51, p.21 (Residential Care Rights).

[49] Submission No.38, p.19 (ACHCA).

[50] Submission No.80, p.9 (ACOSS).

[51] Submission No.34, p.13 (ANF & NSW Nurses Association).

[52] Submission No.58, p.22 (APSF).

[53] Submission No.34, p.13 (ANF & NSW Nurses Association).

[54] Submission No.94, p.50 (DHFS).