(Image: AAP/Dean Lewins)

The aged care royal commission final report, lost amid the controversies in Canberra this week, confirms pretty much everything that the unions representing aged care workers have been telling us for years —  in fact for decades — about the aged care workforce.

And as the commissioners explain, when they have been listened to, the resulting policy responses have been ineffective.

Whether the Morrison government’s response will be any more effective remains to be seen, but the radical nature of the workforce proposals compared to the status quo suggests an extraordinary and expensive challenge. Why is staffing so important? “The evidence is clear that the quality of care and the quality of jobs in aged care are inextricably linked.”

Size

Despite extensive understaffing in the sector, the aged care workforce is already large: 366,000 paid staff, 68,000 volunteers, 28,000 contractors — around 3% of the entire workforce. And it’s going to expand rapidly in coming years. Simply to maintain current (wholly inadequate) staffing levels, the equivalent of an extra 130,000 full time staff will be required in the next 29 years. The commissioners want an additional 80,000 workers by 2030 and an extra 180,000 by 2050 in order to properly staff the sector.

The problem is more acute for Aboriginal and Torres Strait Islander people, who access aged care services less than the rest of the community despite having greater needs, and who often cannot obtain aged care services (or assessments for those services) from other Indigenous people or in-language given the insufficient numbers of Indigenous aged care providers.

The commissioners recommend the establishment of a specific Aboriginal and Torres Strait Islander aged care commissioner to develop an aged care pathway for Indigenous people, and the development of a national Aboriginal and Torres Strait Islander aged care workforce plan.

Pay

Aged care workers are underpaid. The government knows it, and has tried to fix it by throwing more money at aged care providers but they haven’t passed that on in the form of better pay.

In 2018, the Aged Care Workforce Strategy Taskforce recommended a process to transition aged care workers to the same pay levels as their counterparts in the health system, but “there has been no discernible increase in aged care wage rates in the more than two-and-a-half years since the taskforce report was published”.

To fix it, the commissioners want the government, providers and unions to “collaborate on a work value case and equal remuneration application to the Fair Work Commission”, which is asking a lot of a government with a policy of deliberate wage stagnation.

They also want wage increases to become “an explicit policy objective of aged care funding” with the new aged care pricing authority developing a pricing model on that basis.

Staffing levels

Staffing levels have gone backwards, driven by the Howard government’s refusal to mandate minimum staffing ratios.

The commissioners noted that the Productivity Commission found that “the largely unregulated aged care sector provided an incentive to aged care providers to replace higher paid and skilled nurses with lower paid and semi-skilled personal care workers. This is what happened and the trend continues. This trend is the opposite of what should have occurred.”

They now insist that, as part of the new aged care standards, there be a minimum staff ratio: “200 minutes of care per day of which 40 minutes are provided by registered nurses by 2022, and 215 minutes of care per day by 2024, of which 44 minutes are provided by registered nurses. In addition, when fully implemented in 2024, the standard should require at least one registered nurse on site at each residential aged care facility at all times.”

For unions that pointed out the problems that would flow from the Howard government’s 1997 decision at the time, this is a sad vindication.

Professionalisation

The commission wants to turn aged care into a profession with career pathways and accreditation standards that extend to personal care workers as well as trained healthcare staff and nurses.

They proposed registration of personal care workers and a minimum requirement of an Aged Care Certificate III qualification, as well as English language proficiency — two requirements of course that will in the short term reduce the potential workforce for aged care.

How to achieve all this? As we reported earlier this week, commissioner Tony Pagone simply doesn’t trust ministers of bureaucrats to deliver any of this, while Lynelle Briggs wants some key institutions made independent of government but the Health Department to continue overseeing the sector.

Either way, they only believe workforce issues can be addressed with “a fundamental change in the culture, leadership and management of the Department of Health and Aged Care”.

Bureaucrats are poor at fundamental change. And governments are too. Many of these problems — most of them in fact — have been identified before, and not addressed.

What are the chances this time it will be different?