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ESTIMATES COMMITTEE C
DEPARTMENT OF HEALTH, HOUSING, LOCAL GOVERNMENT AND COMMUNITY SERVICES
Program 4--Aged care
Subprogram 4.3--Quality of residential care
- Committee Name
ESTIMATES COMMITTEE C
DEPARTMENT OF HEALTH, HOUSING, LOCAL GOVERNMENT AND COMMUNITY SERVICES
Program 4--Aged care
- Sub program
Subprogram 4.3--Quality of residential care
- System Id
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ESTIMATES COMMITTEE C
(SENATE-Friday, 24 September 1993)
- Start of Business
DEPARTMENT OF HEALTH, HOUSING, LOCAL GOVERNMENT AND COMMUNITY SERVICES
- Program 4--Aged care
DEPARTMENT OF SOCIAL SECURITY
- Program 1--Income security for the retired
- Program 2--Income security for people with disabilities and the sick
- Program 4--Income security for families with children
- Program 5--Provisions for special circumstances
- Program 6--Corporate and other services
- Mr Blunn
Content WindowESTIMATES COMMITTEE C - 24/09/1993 - DEPARTMENT OF HEALTH, HOUSING, LOCAL GOVERNMENT AND COMMUNITY SERVICES - Program 4--Aged care - Subprogram 4.3--Quality of residential care
CHAIRMAN --Ms Murnane, you would recall the line of questioning that was conducted by the Senate Select Committee on Community Services last year in relation to the operation of the RCI. I want to pursue that because I am afraid I am still receiving a great many complaints in Queensland about the way the RCI is operating. I am wondering if you can draw to my attention in the material presented any reference to the RCI and how effectively it is operating from the department's point of view.
Ms Murnane --There have been a number of developments since the Senate inquiry last year and I think that it is best if Mr Griew gives you some of the details of those developments.
CHAIRMAN --I would like to hear them but I am a little bit surprised, given the dissatisfaction with the RCI by a Senate committee, if there is no reference in these estimates. Mr Griew--You will find that, I think, under subprogram 4.4. On about page 282 there is some material but there will be other places as well. I just happen to have my notes open at the page which gives you a distribution of residents across the categories--which is the purpose of the RCI.
CHAIRMAN --But there is no departmental assessment in the estimates of how this new system is working?
Mr Griew --But that is something that the department is doing constantly as we monitor the distribution and the changing distribution of residents. We also are monitoring the concerns people have about the effectiveness of the instrument in identifying the needs of residents with dementia or behavioural and cognitive difficulties.
CHAIRMAN --So you have a document? When you say you are constantly monitoring, you have a document that the members of the committee could have?
Mr Griew --We do not have a single evaluation document. What we have is the constant figures monitoring the distribution of residents, and we could certainly make those available to you.
CHAIRMAN --Do you have details of complaints that you are receiving? Could you document those?
Mr Griew --The minister receives correspondence at different times. I would say that the satisfaction level with the current RCI is not out of proportion. It is not one of the particular areas on which we receive a lot of correspondence.
CHAIRMAN --It is not?
Mr Griew --No.
Ms Murnane --I suppose there are two sides of the RCI that attract attention. One is where it places residents in terms of funding, and I think that it is understandable that the proprietors of nursing homes and the staff in nursing homes would like more funding, but about $1.8 billion is spent on nursing and personal care, so there is a need to judiciously target and ration how that money is spent.
As Mr Griew said, we have got that under continual review.
The other side that attracts a lot of attention, particularly from staff, is documentation and what proprietors and directors of nursing have felt has been an undue emphasis on administration rather than hands-on care. That is an area that we have seriously started to address. Last year, probably just before your Senate committee met, we started to talk to the industry about this and we made substantial changes to the documentation requirements and promulgated those to the industry. It might be useful if we make that document available to you.
CHAIRMAN --Given the extent of the section of the community concerned with aged care and that particular Senate committee, I would have expected some sort of evaluation contained in this documentation showing that the RCI is now working, and whether everybody is happy or not happy, as the case may be. I certainly would like some of that documentation. I would also like to know what continuing liaison has been effected with the Department of Finance about the operation of the RCI. In evidence at that committee we were reassured that there would be ongoing liaison with the Department of Finance, as this process is finance driven.
Could you also take on notice how many visits have been organised for departmental officers from the Department of Finance? The department gave an undertaking to that committee that officers would start to visit nursing homes so that they had a better appreciation of what was required.
Ms Murnane --We can provide that last answer now.
Mr Stevenson --Following on from the request of the Senate standing committee there was a series of visits running over several days, both in the Melbourne metropolitan area and in the Sydney metropolitan area, for senior officers of the Department of Finance. They visited a range of residential facilities and HACC facilities. They met state people involved at the state government level, community groups, day dementia centres, et cetera. We have a standing offer with the Department of Finance. The other thing we wanted them to do was look at some country facilities because they are often different. There is a standing offer with the Department of Finance. Once they are through the budget process, and the officers have time, we will arrange for visits for them to the country areas as well.
CHAIRMAN --Not when they have time. I do not think that was the request of the committee. The request of the committee was to sensitise Department of Finance officers to what they are making decisions about. I think that the only way that they will be in the picture is to see visits to nursing homes as part of that preparatory budget process.
Mr Stevenson --Certainly, they undertook extensive visits in those two cities and there is a standing offer with the Department of Finance to pursue a further program.
CHAIRMAN --I do not suppose they had the opportunity to test their skill in the documentation that nursing staff are required to do on a regular basis?
Mr Stevenson --I accompanied the officers in Melbourne and, in a couple of the nursing homes that we visited, questions about that were asked and nurses showed the type of documentation that is required. I cannot recall in any of the facilities that we visited that there was a major concern expressed about documentation in those homes.
CHAIRMAN --Perhaps that is why they were selected. Am I not cynical?
Senator PATTERSON --I would like you to tell me which nursing homes they were because I have not been to one where people have not complained about documentation. That has to be, in standard monitoring terms, the comment that people make.
Mr Stevenson --I do not have the names of all the homes with me but I can certainly supply the programs.
Senator PATTERSON --I would appreciate it. I think the committee should have those on notice because I certainly will visit the ones in Melbourne and ask them about documentation.
CHAIRMAN --Mr Stevenson, I would have to say I have not been to a nursing home in the last 12 months where documentation is not raised with me as a major concern.
Senator PATTERSON --I agree with you, wholeheartedly.
CHAIRMAN --As you may or may not recall, I was very much of the view that the department did its best under all circumstances and that the villain of the peace was the Department of Finance. That is usually the case, is it not? I am very keen to find out. Do not tell me we have got Department of Finance representatives here?
Senator PATTERSON --The question you should ask them is: how many nursing homes do they visit?
CHAIRMAN --We all accept the need for an effective process. We do accept that, but I think the concern has been that nurses are being turned into administrators. Effectively they are doing the work of perhaps the Department of Finance rather than what they are paid for--and that is nursing care. Further to those general questions, has any work been done on a cost analysis basis of the cost to the department of implementing this new process? What is it costing the department to carry out this new process?
Ms Murnane --We will give you that.
CHAIRMAN --I have here a document from the Queensland nurses union. They have been trialing an alternative that I guess you are aware of called the focal nursing assessment tool.
Mr Griew --We are aware of that.
CHAIRMAN --Small trials have been conducted in Queensland using the focal nursing assessment tool and in the majority of cases the attained category for funding allocation is the same after a 35-minute case conference compared to 21 days of excessive documentation using the RCI. Can you tell me how the department is responding to the work that has been undertaken by the Queensland nurses union in this regard?
Mr Griew --I would like to make a general point about the documentation process and the work that has been commissioned there by the government. There are two major reviews, or one very major review--that is, the review which has been done by Professor Gregory of the nursing home funding structure. One of the issues which he took a lot of evidence on and looked at in some detail was the issue of documentation and administration. When that report is released it will be provided to the committee.
CHAIRMAN --When is that document likely to be released?
Mr Griew --In the fairly near future, I would think. That really is in the hands of the minister, but as soon as it is released it will be provided. Professor Gregory took an interest in that issue and addressed it. As well there was a report commissioned from Mrs Sue Macri, a well-known DON, who now works for the New South Wales Nursing Home and Extended Care Association. She is a respected director of nursing in the industry who was commissioned by the government to look at the documentation required in relation to the resident classification instrument, and her report will also be released at the same time. The government has picked up on that concern about documentation and so have those independent reviewers who will provide some direction for them.
CHAIRMAN --Has the Department of Finance been kept across these developments?
Mr Griew --Yes.
CHAIRMAN --They are aware that their recommendation has led to all this review process and this dissatisfaction?
Ms Murnane --I think I should say that, while our colleagues in the Department of Finance do closely watch expenditure and are concerned about big expenditure jumps, it is not correct to deem them as the authors of this policy.
The RCI is an integral part of the nursing home funding structure and the nursing home reforms that were initiated by the government in 1986, following an extensive review of nursing homes and hostels. Prior to that, as you would be aware, money that went into nursing homes was not necessarily targeted at nursing home residents. Nursing homes had an incentive to take less frail people rather than the people who were most frail and most needed care. The nature of nursing and personal care is that it is demand driven, that the amount of money that a nursing home gets depends--
CHAIRMAN --I am sorry, Ms Murnane, but being demand driven just does not accord with the goals of quality of residential care. When we start to use language like `demand driven', it is totally contrary to the objective at page 259 to optimise the quality of care and quality of life of residents in residential care for the aged subsidised by the Commonwealth. This is my concern, that the language of finance has crept into aged care in a way that I do not believe it has crept into the defence department, the department of administrative services, and a number of other departments. We are talking about demand driven when we are talking about people who are probably among the most vulnerable group in our society. I think that is the principle that nurses and others concerned with this issue have been surprised by: that the language of finance has taken over the language of quality of residential care.
Ms Murnane --Actually, it is the language of social policy. The thrust of the policy is that the more care a person needs, the more money goes into that nursing home for that person.
CHAIRMAN --In theory.
Ms Murnane --No, in practice. That is the case. Many people would undoubtedly like there to be more money in that pool. At the moment, as I said, it is about $1.8 billion dollars to nursing and personal care, and that amount grows. There is no finite cap on it; it grows according to the dependency of residents. We had an agreement with the Department of Finance a couple of years ago that it would not be concerned at growth in nursing and personal care, provided that that growth was within parameters that reflected the predicted growth in the age and dependency of the aged population. So again I have to say that I think we have been able to engage in constructive discussion on policy with the Department of Finance.
Naturally, the Department of Finance is going to look at any demand driven expenditure item, and that is what this is. It does not have a finite cap on it; the final figure that we spend each year depends on the number of people that come into the homes in those categories. So the more category 1s, the more category 2s and the fewer category 5s and 4s, the more the expenditure. That really is the source of it. That comes then back to the director of nursing, who in effect determines how much money is going to come. That is why there is an accountability component to the program and that is why an accountability component is necessary. Whether we have got it right or not is always going to be a matter for discussion. We have got to keep on looking at it, and we are.
Senator PATTERSON --You said that there is no cap on it. Somebody did the 17,000 survey to get the RCI, the original study that worked out the level of dependencies. There was a distribution. Are you with me?
Ms Murnane --Yes, I know what you are talking about.
Senator PATTERSON --We had so many in category 1 and so many in 2, 3, 4 and 5. Every month we get a little update of where it is. I watch it with great interest every month. The category 1s have decreased since then. What was the original number of category 1s in that 17,000 survey?
Mr Griew --The number of category 1s has decreased. The numbers of categories 1, 2 and 3 taken together are very significantly in excess of what they were. So what we have seen is a pattern where the average number of hours of care being funded has been consistently increasing, including an increase of 0.3 of an hour in the last financial year, in the period under discussion.
Senator PATTERSON --But why did the category 1s decrease?
Mr Griew --The number of category 1s has decreased since before the redesign of the instrument which has just been introduced. At the same time, as I said, the numbers of categories 2 and 3 have been increasing. So, overall, the amount of funded care going into nursing homes has increased.
Senator PATTERSON --I would have thought you would still have the same number of people of category 1 type dependency as you did when the thing was developed in 1987.
Ms Murnane --My memory is that there would be 10 per cent in category 1. It is lower than that, and it never reached 10. The reason for that is the application of the instrument. As the instrument has applied to people, people have to be very frail, very sick indeed, to get into category 1. It was predicted that there would be more people in that category and fewer people in categories 2 and 3. In fact, what emerged very early in the piece was that there was a clustering in category 3, and since then there has been a steady growth in category 2.
Directors of nursing often say to me that it is almost impossible to get somebody into category 1. It is not, though. There is a nursing home in Sydney that has about 30 per cent of its residents in category 1. That nursing home has been through an RCI review and that was found to be correct. So it is a feature. It is not that the instrument does not allow anybody to get into category 1; it is a factor that there are not a lot of people at that sort of intensity in most nursing homes--but there are in some.
CHAIRMAN --I want to come back to the focal nursing assessment tool that the Queensland nurses union is trialling. How does the department respond to the claim that it reduces 21 days of documentation to a 35-minute case conference?
Mr Griew --The aim of having an instrument for classifying residents is to be able to classify residents across the country in a relative way so that you can say that the top X per cent will be in this category, the next in the following category, and so on. The problem with having a new instrument--on looking at the focal assessment instrument, this has been our conclusion about it as well--is that it could not serve that relative function for distributing residents across categories. It has some other problems, about which we have written back to the people who wrote to us about it, in terms of the particular areas that it focuses on.
I would come back to the point of the claim about it, which is that it reduces the documentation requirement, and draw you back to the comments I made earlier about the government's intention of looking at that issue anyway through those two reviews and the seriousness of reducing it. I suppose it is the point that Ms Murnane was making about the need to have an instrument that can equitably distribute funding across nursing homes across the nation and also to have an accountability element for that which is not over-intrusive or burdensome on the industry. It is getting that balance right, rather than perhaps starting again on the instrument.
CHAIRMAN --But clearly the RCI is not satisfactory. That is essentially what you are saying. You have got the Queensland nurses union trialling this pilot one. You have got Professor Gregory and Susan Macri looking at the whole question of reviewing, among other things, the use of the RCI, so obviously the RCI has not delivered in the way that you hoped it would. It has just created a great deal of unhappiness in nursing homes in the process.
Mr Griew --I think I should clarify. I am certainly not saying that the RCI is unsatisfactory. What I was wanting to say is that I think that an instrument that can distribute people in the way that the RCI is doing, and therefore allow for an equitable distribution of funding according to need, is essential. What I am saying is that I think the element that people are actually talking about is the documentation and accountability that goes with it, and that it may be that we need to examine our practices there, rather than in the principle of the thing and the instrument itself.
CHAIRMAN --The principle I do not think anybody disagrees with. Of course there has to be accountability, but if you look at accountability across other areas of government expenditure, can you imagine what fun it would be to design an RCI for the defence department to have them account in a similar way for their funding? You could have a great deal of fun with that.
Ms Murnane --We cannot answer for what the Department of Defence does, but we have to continually keep that documentation, those accountability requirements, under review. There have been changes and there will probably be more changes. But I think I do have to say that nursing homes are not required to document extensively for 21 days. They are required to observe over 21 days and that can be reviewed. Maybe you can reach a decision in less time than that. Nursing homes themselves did not want to have to reach a decision quickly because they thought they might underclassify somebody if they did it. That was in the early days. I think it is important to put on the record that many nursing homes believe that documentation requirements are much more stringent than they actually are, and some of them have an internal policy for documentation that is certainly not the documentation they require. They do that for a number of reasons, and one of the reasons is that they believe that the more extensive their documentation, the less likely, if their decisions are reviewed, that they will be changed. We have said that is not the case.
CHAIRMAN --Some of the teams are telling them that. I have a letter here from the deputy mayor of Townsville and she has had various complaints. She says:
From this background and my personal investigation of the complaints raised . . . I can say clearly that the documentation requirements for aged care adds an enormous workload . . . I must question whether this documentation is entirely necessary . . .
However, she says:
. . . the administration have been told that their documentation must improve or funding may be reduced.
So you have got this catch 22. In Canberra and in Brisbane, people in the department are making reassuring noises and are telling us about accountability. We cannot disagree with that, but out there in the field, nursing home administrators are being told, `You have got to put more time into your documentation'. That is certainly still happening in Queensland.
Mr Cole --I think that we are getting the same message from the industry, that the documentation requirements are excessive. We have been telling them for quite some time that they document rather more than they need to. But, for whatever reason, they are still doing it and they are still complaining about the documentation requirements. We do take it seriously, and the fact that Gregory is looking at it and the fact that Macri has looked at it are really an earnest of how seriously we are taking it. I would hope that around this time next year, when we are examining this program, we will have fewer complaints about this matter.
CHAIRMAN --And in the meantime, we will get the cost analysis and that other document that you have prepared that shows that the extent of documentation has been reduced, I think you were saying?
Ms Murnane --Yes, I think it would be useful if we actually have the requirements in front of us when we discuss it next time so that we are talking about what the department is requiring. The other part of that discussion is what some nursing homes think they are required to do, or do.
Senator PATTERSON --I would like to make a suggestion that at some stage between now and when we have our supplementary estimates the committee has a meeting with the department to see the documentation.
Ms Murnane --Yes, that would be good.
CHAIRMAN --Professor Gregory's report may be ready by the time we have our next meeting; perhaps not, perhaps it is too soon.
Ms Murnane --Maybe it will.
Senator PATTERSON --Can I just ask one question to clarify something for me. When a standards monitoring team visits a nursing home and a nursing home reaches 31 mets, as they now use the lingo, when would a nursing home expect to have another visit from a standards monitoring team? How long does that last for? What is the durability of a 31 mets?
Mr Stevenson --Normally, we would work on a two-year cycle; that is the average. We aim to visit each nursing home on average for two years.
Senator PATTERSON --Is that on average for two years, or on average every two years?
Mr Stevenson --It is every two years. When a standards monitoring team visits a home it goes through the process with the home and comes up with a report. The home has a chance to comment on it, put up an action plan and that is published. That represents the situation at that time. If the home is a home that has certainly got 31 mets, the department would not be visiting that home for the purpose of standards monitoring again within the two-year period unless some circumstances changed in that time which led the department to develop some concerns about the home. For example, if a spate of serious complaints were received by the department that would occasion, possibly, a visit. Sometimes with the change of proprietor, change of DON or other indicators like that the performance of a home can alter, but we would not be expecting to visit a stable home that performs at that level more frequently than two years.
Senator PATTERSON --You would expect that, if a nursing home had met 31 of the standards, had not changed the DON or proprietor but had had seven more visits in less than 12 months, that was excessive?
Mr Stevenson --I would have to look at the circumstances of the case. The only reason I could think that would occasion a circumstance like that was if a series of complaints were received by the department. The department has the duty of care to try to substantiate those complaints. Often complaints are not substantiated but the department has the duty of care--
Senator PATTERSON --But if a nursing home has 31 mets and a situation arises like that, does the department look at whether there is any possibility that a conflict might have arisen between the particular STM team and the nursing home itself and maybe look at trying to negotiate that situation? I could imagine a situation arising where somebody has taken a personal dislike or there has been some animosity in the previous meeting. Is there a way of resolving problems when you see a problem between a particular STM and a nursing home?
Mr Stevenson --There certainly is. We make a particular effort with our program managers to make it very clear that our program managers are, in our state offices and our regional offices in areas like Queensland, responsible for the program. They represent the delegate; they are responsible for the department's statement. We are making it clear to the industry and clear to those program managers that where a nursing home has concerns about the process that is being undertaken by a standards monitoring team they should bring those quickly to the attention of the program manager and the program manager should move quickly to meet with the home and discuss those matters. If they are individual complaints about individual officers, I think, as we have said before, that is a matter for the department as an employer to investigate and, if necessary, correct the performance or the behaviour of the individual. In terms of any complaints that a proprietor has about the process, the program manager is there.
In the context of the Braithwaite report on outcome standards we are also looking at ways at making the process even more transparent and developing means to do this. These matters have not been decided by the minister yet but, for example, one we are looking at is where there are serious concerns about particular aspects of the process; or where, on those rare occasions a nursing issue comes up, to possibly use a body such as a standards review panel--they are well regarded by the industry at the moment--to provide advice to the program manager and proprietor in those circumstances.
Senator PATTERSON --But you would admit that you could have a vexatious person who understands the system and could get at a nursing home proprietor or management by making vexatious complaints? That is a possibility if you know the system, is it not?
Ms Murnane --The system has got to be structured so that if that does happen it is quickly detected and overcome. But if you would give me the name of that nursing home we will have a good look at that, and give you a report on it.
Senator PATTERSON --Thank you.
Mr Cole --If something like that was happening we would like to know about it and see what lies behind it. Frankly, I am appalled at the thought that somebody could get 31 mets and then have seven more visits--unless there is something really strange going on that I need to know about.
Senator PATTERSON --I would agree with you, Mr Cole.
CHAIRMAN --There being no further questions for the department, thank you very much, Minister, Mr Cole and officers. I just have a number of questions on notice from Senator Patterson. Is it the wish of the committee that the questions be incorporated in Hansard? There being no objection, it is so ordered.
[The questions appear at the conclusion of today's proceedings.]