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Standing Committee on Health, Aged Care and Sport
Quality of care in residential aged-care facilities in Australia

JOLLY, Ms Maria, First Assistant Secretary, Aged Care Reform Taskforce, Department of Health

LAFFAN, Ms Amy, Assistant Secretary, Aged Care Quality and Regulatory Reform Branch, Department of Health

MOND, Ms Jo, Assistant Secretary, Specialised Programs and Regulation Branch, Department of Health

SMITH, Mr Jaye, First Assistant Secretary, Residential and Flexible Aged Care Division, Department of Health

STUDDERT, Dr Lisa, Deputy Secretary, Aged Care Sport and Population Health Group, Department of Health

Committee met at 12:10

CHAIR ( Mr Zimmerman ): I declare open this public hearing of the Standing Committee on Health, Aged Care and Sport in relation to its inquiry into residential aged care. Welcome to the Department of Health. I remind you that these are formal proceedings of the parliament. Giving false or misleading evidence is a serious matter and could result in a contempt of parliament. The evidence given today is being recorded by Hansard and attracts parliamentary privilege.

This is obviously the second time that we've had the opportunity to have a discussion with you about this inquiry. We thought it might be useful, as we come to the tail end of the inquiry, to have you back. Committee members would be aware that the department provided an initial submission and in our papers there are also a number of questions on notice that the department has answered more recently. There have obviously been quite a few developments since this inquiry got under way. It is a bit of a movable feast. Did you want to make an opening statement?

Dr Studdert : Yes, thank you. As you've noted, there have been quite a few developments since you heard from my colleagues a few months ago. I'll give you a quick overview of those and then, of course, the team are available to answer any questions on the more recent announcements in this space or anything else you may want to ask about.

Thank you again for the opportunity to appear. At our appearance on 1 March, the department provided an opening statement with background on the role of the department in aged care quality arrangements and a summary of reforms implemented and underway to promote and improve the quality of residential aged care services. Given the time that has passed, as I mentioned, we will provide an update to the committee on the 2018-19 budget, particularly the government's More Choices for a Longer Life Package and its relevant measures. The package is funded by a new program structure which combines funding for residential aged care and home care packages into one program. Many of the aged care measures have been guided by the recommendations of the Carnell Paterson review, the Tune aged care legislative review, the Australian Law Reform Commission inquiry into elder abuse, and the Australian Human Rights Commission's Willing to work inquiry.

The three primary elements of the budget package for aged care are better access to care, better quality of care, and better ageing. Some of the measures relevant to this inquiry include better protection for consumers and ensuring quality by establishing a new Aged Care Quality and Safety Commission; bringing together the functions of the Australian Aged Care Quality Agency and the Aged Care Complaints Commissioner from 1 January 2019 and the aged care regulatory functions within the department from 1 January 2020; developing a robust risk profiling approach to support the new commission identify and quickly respond to individual and systemic risks and care failures by aged care providers; introducing a performance rating for residential aged care service providers against the new quality standards; and supporting residential care providers to transition to the new quality arrangements. Additionally, palliative care and better care for people living with dementia; improved access to psychological services for residents of aged care; and a pilot of a national program to address social isolation and loneliness in people 75 years and over. I'll leave my remarks there. We are very happy to take any questions.

CHAIR: Obviously there have been a lot of government announcements arising from the Carnell Paterson review. Which Carnell Paterson recommendations has the government not made a final determination about? What's left?

Ms Jolly : What's left? I think the recommendations to establish the new agency and the measures that Lisa's referred to pretty well covers the territory. The model that's been put forward is slightly different to the model that was recommended by Carnell-Paterson, but the intent and the bringing together of a regulatory function into a stronger quality care system I think is absolutely consistent with Carnell-Paterson.

CHAIR: What are the differences in the model?

Ms Jolly : The Carnell-Paterson review recommended several commissioners within an agency, and the model that we've put forward is a single commissioner with a clinical care advisory structure to support that commissioner. That's probably the main—

CHAIR: So there'd be a single commissioner, who performs the functions of both the previous complaints commissioner and the head of the quality agency.

Ms Jolly : Yes. Also, from 2020 the department's functions in compliance will go into that single agency.

CHAIR: It would be a single point of compliance. Have any decisions been made about who the commissioner will be?

Ms Jolly : No, not at this stage.

CHAIR: When is that likely to be?

Dr Studdert : There will be a recruitment process, and that will start in the next few months, I would expect.

CHAIR: In summary, you don't believe there are any recommendations in the Carnell-Paterson review that the government hasn't committed to implementing.

Ms Jolly : I don't think there is anything that is outstanding in the Carnell—

Ms Laffan : Noting that Carnell-Paterson had their recommendations and then numerous actions that fit within those recommendations, but in terms of the recommendations, the budget is a response to each of those.

CHAIR: Could you walk the committee through the new standards which come into effect on 1 July. There remain 44, is that correct?

Ms Laffan : No. I don't have the latest count on me, but I think it's around 42 standards if you count each individual item.

CHAIR: What would you say were the main differences between the existing standards and the new standards?

Ms Laffan : Firstly, the existing standards—the 44 that you referred to—were for existing residential care only. The new set of standards will cover residential, flexible care, transition care, home care and CHSP. They're far more consumer-outcome focused. The very first thing you read on each of the standards is the outcome for the consumer—so an 'I' statement: I feel this; this is what good care would mean for me as an individual—

CHAIR: Give me an example of that in practice. Would you say it's a rewriting of the existing standards in that form or are a wholly different—

Ms Laffan : No, it's not. They're whole new standards. I wouldn't say that we revised the standards; we actually started from scratch—we started again. Obviously, we looked at lots of different research we had. We looked at data we had from the quality agency and the complaints commissioner, at the most-common complaints, at the most-common areas of noncompliance. We looked internationally at the way standards were written. We looked at what NDIS is doing and at what they're doing in the health commission. It was informed by other things, but we didn't draw a direct line to old standards and say, 'Oh, what does it say in the new standards?'. Throughout the process we've been co-designing the standards with the technical advisory group, which includes consumers, providers, experts in standards, experts in standards in health care.

CHAIR: Back to my initial question: have you got a practical example of how the new standards will apply?

Ms Laffan : Standard 1 is 'Consumer dignity and choice'. Actually, this standard underpins every single standard, and it starts with a consumer outcome which says:

I am treated with dignity and respect, and can maintain my identity. I can make informed choices about my care and services, and live the life I choose.

Then it goes into an organisational statement and then the requirements, which are the standards themselves. When I mentioned there are about 40, that's the sort of things that I'm counting. For example, the organisational statement reflects the concepts in the outcome. Requirement 1.1 says:

Each consumer is treated with dignity and respect, and their identity, culture and diversity is valued.

That's what the provider is tested on.

CHAIR: What did the department identify as the weaknesses with the existing standards that needed rectification?

Ms Laffan : Firstly there was the additional regulation when you have many providers who provide multiple care types. That's difficult for providers—some of them are meeting up to four sets of standards—and difficult for consumers also. As you're probably aware, consumers might start off in CHSP, move to home care and then into residential care. It helps them know what their expectations can be right through that continuum of care.

We also found that the current standards are a bit repetitive and duplicative. For example, if you look at the current standards, about four times it talks about continuous improvement in various different outcome areas. We've put in the new standards one single standard on continuous improvement—continuous improvement across all of the care and services—but it doesn't need to be replicated in every single activity.

CHAIR: I have two other issues of the many that have been raised with us. A topical issue for this inquiry has been the issue of staff ratios, particularly the engagement of nurses and registered nurses. As you'd be aware, the aged-care providers are not particularly keen on mandated ratios; whereas the unions and some consumer groups are. I'm just wondering whether you have any reflections on that, and I preface that with the statement that we have heard evidence, including from the AMA, of some pretty horrific examples where care in facilities was not meeting the needs of patients. I cite, for example, one example from one of the AMA representatives where he was required to perform minor but not insignificant urgent surgery in an aged-care facility. There was no nursing staff available, so an ancillary worker assisted and was traumatised by that process. He pointed to that as being a problem of where there wasn't a requirement that registered nurses be present at all times in an aged-care facility.

Ms Laffan : Under the Aged Care Act and repeated in the standards is the requirement that approved providers have an adequate number of appropriately skilled staff. So it's the responsibility of the individual aged-care home to determine the skills mix and number based on the needs of each care recipient. In terms of nursing, it's also determined by the care needs of care recipients, and Commonwealth law does set out some instances where nurses are required—for example, in the delivery of complex nursing procedures, in the care planning and assessment. There's also state and territory legislation which requires registered nurses for particular activities.

CHAIR: Particularly with the changing nature of aged care, why wouldn't there be at least a minimum requirement for registered nurses being present? It's hard to think of an aged-care facility these days, considering the higher needs of most aged-care clients—for example, the dispensation of medication et cetera—where you wouldn't need a registered nurse on call.

Ms Laffan : Dispensation of medication and things like that can be done by personal care assistants by legislation, so you don't actually need a registered nurse to do some of those activities. That's what the state and territory legislation covers. The legislation says it's determined by the care needs of the care recipients and, clearly, that fluctuates over time on any given day or any given week or year.

CHAIR: Does the department have access to workforce figures which would track the structure of the workforce over, say, the last decade or last five years?

Ms Laffan : We do have a workforce survey.

Dr Studdert : In the aged-care area in particular, or across all health systems?

CHAIR: No, for residential aged care.

Ms Laffan : There's a workforce survey that might well—

CHAIR: What I'm wondering is whether you have statistics that, in broad terms, say that in 2018, there's a workforce of 20,000 people: of these, 5,000 are registered nurses; and 3,000 are ancillary staff et cetera—effectively, a longitudinal analysis of five or 10 years ago that this is what the similar proportion would be?

Ms Laffan : Having anticipated this sort of question—I'm just trying to find—

Ms Mond : There was the 2016 national aged care workforce census, and the survey found that overall staffing ratios and the proportion of registered nurses in the residential sector had remained constant since 2012. So that census has provided data that looks at the change between the 2012 and the 2016—

CHAIR: Would you be able to provide the committee with a summation of that—maybe not the whole report but just the headline trends.

Ms Mond : Absolutely.

CHAIR: I'll finish on this topic: in an environment where the health needs of most residential aged-care residents has increased as it's moved effectively to a high-care model, does this strike you as odd—so the health needs of residents has increased, but the number of nurses has remained static, proportionally?

Dr Studdert : It's very hard to comment on that. As an overall picture, there are many other variables that are in the mix—the way care is delivered, the settings in which it's delivered and the qualification and skills of the other support staff. It'd be pretty hard to make a broad comment on that, but I think we can certainly provide the data from that survey.

CHAIR: That would be very helpful. Thank you. I have a final question. What regulations are there about the use of restraints in residential aged-care facilities?

Ms Laffan : Under the current standards, we have requirements around behavioural management. There's also the Result and processes guide, which talks about restraints being used as a last resort, underpinning the standards. We've also given to each and every aged-care provider a decision tool, which talks about the use of restraint in aged care. Again, it's about being a last resort and having discussions with the person themselves, their family members and their medical team.

Dr FREELANDER: I want to go back to the issue of the staff ratios. Given that care needs are often unpredictable and that the health needs in residential aged care seem to be becoming more complex—we've had a lot of evidence about this—can you still say that you don't think the mandatory presence of registered nurses should be a primary care need?

Dr Studdert : I think you're asking for an opinion there, which we can't provide. Ms Laffan has explained the current standards, which are around the quality of care and the obligation on the provider to ensure that.

Ms Jolly : Can I also refer you to some other inquiries into the issue of ratios, in particular the Productivity Commission's. I understand they talked about ratios as being a blunt instrument—I think that was the phrase—in trying to establish the quality of care and skills mix. There are a range of documented opinions about the value of ratios in addition to the existing arrangements.

Dr FREELANDER: Do we keep statistics on the number of hospital transfers from residential aged care? Do we have any details on that at all?

Mr Smith : I'm not sure that we have any specific data on that. We can certainly have a look, but I'm not sure that we have that. We can take that on notice.

Dr FREELANDER: Do you have a view on the mandatory training requirements for residential aged-care workers and accreditation and registration?

Ms Jolly : That's a matter that's been looked at as part of the industry workforce strategy that's currently being developed. I know that looking at issues to do with accreditation, standards, training and career pathways is all very much part of the discussion. That final strategy document is due at the end of June. It will talk about some of those issues. I think the chair of that task force, Professor John Pollaers, has been talking about the sorts of strategies that the industry should be looking at, including more consistent career pathways and accreditation arrangements.

Dr FREELANDER: We've also been given some evidence about the care of people with dementia in residential aged care. There seem to be divergent views as to whether there should be dementia-specific units or whether residential aged-care units should be able to deal with people with dementia. Do you have any views on that?

Ms Mond : Firstly, I'd premise it by saying about 52 per cent of residents within the residential aged-care facility have some form of dementia, so it becomes important to ensure that services across residential aged care cater for the needs of people with dementia and also varying forms of dementia. So we do have a number of different supports, from advocacy-type services and also specific dementia services around severe-behaviour response teams. And we're also currently in a design phase looking at how we would implement a third tier of servicing, which is around a specialist dementia care units for those people with the very severe behaviours that can present with dementia.

Dr FREELANDER: Sort of graduated responses.

Ms Mond : Absolutely.

Mr TIM WILSON: One of the concerns I have—and it's probably a bit more macro; it's about managing people in terms of lifecycles of care—is that there is obviously a big focus on home care packages, and that includes what was announced recently in the federal budget. But what that's doing is leading to more people staying in their homes for longer periods of time, meaning that when they go into nursing homes, they're normally at a later stage of life and facing much more acute problems. Has the department looked at, or is there any work looking at, how that is changing the nature and the focus of aged care—not only its financial sustainability but also what it means in terms of the support infrastructure that people need when they're potentially going to be in aged care for a much shorter period of time but at a much higher care level?

Dr Studdert : I might start: I think that's absolutely the nub of what we are observing and experiencing in terms of all the elements of service delivery and funding support that the Commonwealth provides. It's what underlies the restructuring of funding profiles in the current budget package, and it's what Ms Mond referred to in terms of the need for increased and enhanced attention to dementia and the underlying funding profiles that go with that. So yes, we are very conscious of the demographic transition, if you like, both macro for the population as a whole and for our ageing population. That is also very much at the nub of what the Tune review looked at in terms of the changing elements of the sector.

Mr TIM WILSON: But in terms of the monitoring environment around how individual providers are adjusting their services to make sure they are meeting that: is there an ongoing collection of metrics or data that's analysed to see whether care providers are shifting with it?

Mr Smith : There is a piece of work under way at the moment called the Resource Utilisation and Classification Study. I guess, in addition to the overriding principle that providers need to provide the level of care for the recipients of care who are in their facility based on their needs—and if they're getting more complex and people are more frail, then that's still the overriding principle in the act—there is a recognition that we do need to do some work about the funding model, and to make sure that's contemporary enough to keep up with the changing needs of care recipients. The Resource Utilisation and Classification Study, or RUCS for short, is intended to identify the clinical and need characteristics of aged-care recipients that initially influence the cost of care; and identify the proportion of care costs that are shared across relatives, relative to those costs that are related to an individual's actual needs—and that's going to the fact that people are making different choices about the time at which they enter into residential care, and that, potentially, their needs are therefore varying. There are a couple of studies in relation to those two elements that are currently underway. The idea is that those two studies will inform the development of a casemix classification based on the identified cost drivers that can underpin a funding model that recognises both shared and variable costs. That's also going to have a look at the location at which services are provided, so it will take into account the costs of services provided in more regional and remote areas. It's a piece of work that's underway and it's going to take a little time to unfold, but we're engaged closely with the sector, and a large number of providers are engaging in these studies. Government is keen to see a response to that piece of work to really inform options about the way in which funding for residential care might need to be reformed.

Mr TIM WILSON: I say that because—with that changing structure, with people being in care for shorter periods of time—one of my concerns is that, to ensure that there is the proper investment in the availability of aged care, it's going to change the financial incentives models dramatically. It seems to me that, based on the data I've seen, as a country, we're going to face a challenge around that. There's going to be a challenge both in keeping the existing providers open in all of their residential homes as well as in building new ones. What's the time frame for the completion? I know you said it was a while.

Mr Smith : The two studies that are currently underway will be completed between August and October this year to inform the third study, which is actually developing that case mix model, which is intended to occur, if all those time lines hold, in the November to January period. That would then form a report back to government about what that shows.

Ms LANDRY: It's been put to the committee that the Aged Care Funding Instrument is no longer fit for purpose and is not able to provide a contemporary range of care for consumers. What's the department's response to this characterisation? Also, are there plans to modernise the ACFI to allow more flexibility in the services provided?

Mr Smith : I think that really goes to the point I was just making about the Resource Utilisation and Classification Study. It is a recognition that we need to examine more contemporary ways of looking at the needs of care recipients and how they are funded by government and, indeed, noting that it's not always one size fits all. There are shared costs. When you're running a facility with many people in it, there are costs that can be shared across residents, but then there are also very specific needs. We're trying, through the RUC Study, to get a lot more fidelity on that. Moving away from ACFI, given that the business models are all built around ACFI, is a key consideration, and, obviously, whatever comes out of the RUC Study is then going to have to be informed by the implementation issues associated with that and what it might mean for the sector, but it's absolutely a piece that is underway and is a priority.

Mrs WICKS: I was interested in the statements that you made around reframing things so that it was meeting the needs of residents, and they were able to say, 'I feel this,' or 'I need this.' It sounds commendable. I'm also interested in the need to make sure that there are strong mental health support services around individuals. Knowing a little bit about this issue, how do you reconcile that when perhaps individuals don't necessarily know what they may need? What is the approach to making sure there are adequate welfare services around the needs of residents, particularly in terms of earlier intervention?

Dr Studdert : There's a combination of elements to that answer. One is the quality standards, which absolutely directs providers to be attuned to and responsive to individual needs—

Ms Laffan : And to provide support for those people who might have cognitive impairment or might not be able to express their wishes. It's to provide that support around them so that they can make the choices that they are able to make.

Dr Studdert : And in consultation with their families. Then, on mental health in particular, we do have a measure in our budget which is to do more and to trial some different approaches to delivering mental health services in residential aged care.

Mr Smith : I can give a little bit of overview on that measure. The recent announcement in the budget of the More Choices for a Longer Life package delivered a mental health package for people with a diagnosed mental health condition living in residential aged care facilities. It's $82.5 million over four years. The implementation of that is still being worked through. We do know it would roll out through primary health networks, and it's really recognising the role that PHNs already play in commissioning community mental health services and building on that capacity but taking into account, again, the PHN model, which is about what the needs are in this particular area. So it's about building a mental health response within that PHN within the facilities there that meet the identified needs of the area. Obviously, there is a piece of work to do with the PHNs in particular in terms of the commissioning of those services and rolling them out.

Dr Studdert : And with the aged-care providers in those areas. It would be a joint piece of work that we'll work on with the PHNs and the aged-care providers. It's a very timely question and one that we're looking at quite actively now with this new budget money.

CHAIR: We heard evidence from Painaustralia, who indicated that the department was funding their guide Pain in Residential Aged Care Facilities: Management Strategies. I think one of the concerns they raise is that this is obviously an excellent resource tool but they weren't quite sure whether the department was going to fund the production, distribution and follow-up training for that guide. You might want to take that on notice.

Ms Laffan : We will, but I would just add that my team has been in discussion with Painaustralia so that the standards and that guidance align with each other. I believe I'm meeting with Painaustralia in the next few weeks.

Dr Studdert : It would certainly be in all our interests to ensure that the resource got distributed and adopted, so we can certainly pursue that.

CHAIR: Indeed. It's a hefty, expensive document. We might have to get Clive Palmer to print it! I just want to explore the issue of the star rating system that the minister has flagged will be incorporated with the myagedcare website. Where is the thinking on the development of that? How will that operate?

Ms Laffan : In fact it won't be a star rating system; it will be a differentiated system based on performance against the quality standards. At the moment, we know that providers either get a 'met' or 'not met' ranking. Probably about 95 per cent of providers get that 'met' rating. That's not overly useful for consumers to differentiate the performance of—

CHAIR: 'Met' or 'not met' for all 44 standards, or just one in globo?

Ms Laffan : They have 'met' or 'not met' against each standard. The idea of the differentiated system will be finding more categories, different differentiations, so that consumers can better understand how providers are performing against those quality standards and can make informed decisions based on that.

CHAIR: If I'm a consumer, what will it look like?

Ms Laffan : That's something that we'll be working through with stakeholders, and particularly with consumers. Rather than the two areas of differentiation, you could have multiple areas. How useful is that to consumers? Do you have particular phrases like 'excellent' or 'good'? Do you have percentages? Do you have red or green lights? Those sorts of things will all be worked through as part of our co-design process.

CHAIR: Carnell Paterson recommended a star rated system, didn't they?

Ms Laffan : That's right.

CHAIR: Why are you not pursuing the star rated system?

Ms Laffan : A star rating system often has the feeling of a consumer rated system—your TripAdvisor kind of function—whereas this differentiated system will be based on performance against the standards. Of course consumer views are taken into account. They're taken into account as part of the assessment of the standards. But it's not the sort of system where someone will go online and say, 'I give this place four stars.'

CHAIR: I'm not quite sure that that's right. Most people associate star rating systems with hotels, I would suspect, and increasingly with white-good products. In both of those cases, it's always third parties that are doing the star rating systems. If you go to TripAdvisor, it's more a ranking system than a starring system. So I'm not quite sure that that's entirely—

Ms Laffan : And we may well find, as part of our consultation, that stars are the thing that resonates best with consumers, or it might be some other kind of label.

CHAIR: I would have thought a simple system. I suppose people will be, because it's important, but, if you're expecting people to effectively read through an analysis of how people meet 42 different standards, it adds a degree of complexity.

Ms Laffan : The idea is to provide that transparency and assistance for consumers to make choices, so the ease of consumer deciding and differentiation will absolutely be key to making the decision about what we use.

CHAIR: Before you introduce this system, will you effectively focus-group-test it, in the way that someone would when bringing a new product to market?

Ms Laffan : I would think so. We'd be heavily talking to consumer groups.

CHAIR: But not with consumer groups, with consumers?

Ms Laffan : Sorry; consumer peaks and consumers themselves.

CHAIR: So you'll focus-group it with potential consumers to assess its usability?

Ms Laffan : Yes, and in fact that's what we've done with standards and charters and things like that.

CHAIR: Who, under the new structure, is having responsibility for the myagedcare website? Is that the department or the new agency?

Ms Laffan : That's the department.

CHAIR: Are there any further questions? No. There were a couple of matters that I think you agreed to take on notice. If you can respond to the committee by two weeks from today, that would be very helpful. If we have any further questions, then we'll place those on notice with you. Thank you again for appearing for a second bite at the cherry.

Committee adjourned 12:45