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Community Affairs References Committee
23/02/2017
Future of Australia's aged-care sector workforce

KRAAK, Mr Graham, Acting Senior Director, Strategic Policy and Legislation Branch, Strategic Policy and Planning Division, Queensland Health

[09:19]

CHAIR: Welcome. Has information on parliamentary privilege and the protection of witnesses and evidence has been provided to you?

Mr Kraak : Yes.

CHAIR: I remind witnesses that the Senate has resolved that an officer of a department of the Commonwealth or of a state shall not be asked to give opinions on matters of policy and shall be given reasonable opportunity to refer questions asked of the officer to superior officers or to a minister. This resolution prohibits only questions asking for opinions on matters of policy and does not preclude questions asking for explanations of policy or factual questions about how and when policies were adopted. I invite you to make an opening statement. Thank you for your submission. After you have made an opening statement, we will ask you some questions.

Mr Kraak : Firstly, I would like to acknowledge the traditional custodians of the land on which we meet and pay my respects to their leaders past, current and emerging. I would like to express my appreciation to the committee for its willingness to travel to Townsville and other regional areas. I think it is very important to get an understanding of the complexity of the workforce issues throughout the country, and particularly in Queensland, given it is a decentralised state and given its vast distances between populations. The other point I wanted to make was about the high level of interdependency between the health sector and the aged-care sector in terms of the services that are provided. I will not reiterate what is in the submission that was provided some 12 months ago, but there have been some emerging things that have happened in the last 12 months I would like to draw the committee's attention to.

Firstly, we recently released a vision of the health system. This is a 10-year vision and it is driven by the increasing demand for health services, the ageing population and the variation in health outcomes for particular population groups. Advancing health 2026 has four directions: promoting wellbeing and healthy ageing via preventative strategies; delivering health care that is clinically appropriate for complex care needs, including for older people and culturally appropriate for Aboriginal and Torres Strait Islanders; connecting health care across the continuum—this is particularly recognising that health care is not simply the domain of healthcare services or public health services but is also the domain of private health services and that health is actually provided in aged-care services as well; and, finally, pursuing innovation. Key to achieving our vision is a vibrant and agile workforce. To that end, a key focus of the vision is empowering our workforce and a commitment to develop a 10-year health workforce strategy, which is likely to be released later this year. I have printed copies of the vision document here for you.

The other point I would like to make is about the interface between the public health system and the Commonwealth-funded aged-care system. It is a particular issue for us, mainly because we see that timely access to assessment services and basic home support and home modification services and access to community and residential based care assist an older person to return to the community much sooner, assist an older person to receive the care that they require, reduce carer stress, maximise independence and reduce the effects of prolonged hospitalisation. To that end, Queensland Health has conducted censuses of longer-stay older patients in public hospitals. These censuses initially have been done over a number of years. There was formerly a national partnership agreement for longer-stay older patients, under which the Commonwealth provided some funding to states and territories in recognition of older people remaining in public hospitals longer than they necessarily were required to. That national partnership agreement has since expired but in 2016 the long stay older patients census identified 319 public patients who met the criteria of no longer requiring acute care in a public hospital, of being aged over 65—or 50 if an Aboriginal or Torres Strait Islander—and of actually remaining in a public hospital. The interesting thing is that the occupied bed days between the previous census and this census doubled. The length of time that these people remained in hospital between the census date and when they were declared medically stable effectively almost doubled. I think it is really important to emphasise, as I mentioned before, that older people have just as much right to access public hospital services when they need these services. The focus of the census is about identifying the barriers for older people being able to access the right care at the right time and treating their families with dignity and respect.

The leading reasons for people remaining in hospital were, firstly, waiting for a residential bed, which accounted for just over half of the longer stay older patients. The second reason in the 2016 census was 'difficult to place due to behaviour and dementia'.

CHAIR: Could you please say that again?

Mr Kraak : 'Difficult to place due to behavioural issues and dementia'. The reason for raising that is that these are particular key issues in terms of matters for workforce management of aged people. The other point I want to make is the impact of the NDIS, the National Disability Insurance Scheme. Once it is fully implemented in Queensland, by 30 June 2019, it is expected that about 90,000 people with significant or profound disabilities will be supported through the NDIS. This compares to about 45,000 people at the moment. The NDIS is expected to create about 15,000 to 19,000 additional jobs for Queensland during this transition period and it is expected that the main roles will be disability support workers, allied health clinicians and assistants, and office based roles like finance and administration. Based on national projections, we think it is not unrealistic to expect that the additional workforce requirements in Queensland as a result of the NDIS will be around about 2,000 allied health professionals, 550 nurses—possibly mainly enrolled nurses—with the vast majority being disability support workers. Our view is that this growth will increase the demand for competition for workers in the social service sector, specifically roles required for both aged care and the disability system, as personal care workers or disability support workers and assistants in nursing will be highly sought after.

The increase in demand in the workforce arising from the NDIS and the expected increase in choice and competition of the roles is not expected to have a significant impact on Queensland Health. This is primarily due to employment conditions support and future job opportunities, and they will continue to make the public health system probably a more attractive option for workers and for existing employees. As such, we see that the biggest impact is actually going to be on the non-government sector.

In conclusion, I have spoken a lot about the challenges. I do think that there are some opportunities, including attracting the workforce to health and the community services system in general. We know that the demand for health workers within the health system, within the aged-care system and within the disability system is going to grow, so we need to attract workers to the social support services system as much as possible. We see that there is a need to improve rewards. It is not just about remuneration; it is also about intrinsic motivators and opportunities for professional development. I think there was a mention before about not referring to aged care as sexy, but I think there is an important issue about improving the image of working in aged care.

These things are probably about clinical load, the clinical support mechanisms and workforce pathways. We see a significant need to focus on retaining the existing workforce, in particular, for nurses. In our submission we identified that there is a significant reduction in professionalisation—that is, the reduction of registered nurses within the aged care workforce. That has continued over a number of years. It is important to actually retain a level of professionalisation and a level of expert clinical supervision.

Retaining the workforce we believe can be improved by improving employment security. There is a significant level of casualisation and part-time employment or underemployment within the aged-care sector. We also see that there is encouraging the workforce to work to their full scope of practice. This is probably challenging some of the existing work practices and paradigms. For registered nurses, this will mean less direct care delivery and more direct clinical management, clinical supervision and clinical oversight.

Finally, we believe that there is benefit in future planning. We believe that we cannot prepare for some of the challenges without a plan to actually address some of those particular challenges. And that cannot be done by government alone; it has to be done in conjunction with industry, employee representative organisations and, most importantly, consumers. Thank you.

Senator POLLEY: I will start off where I tried to end with the previous witnesses. Do you believe that standardisation of qualifications and a national register of those people who are working in caring for older Australians is required?

Mr Kraak : I do not think that the costs of actually developing something would deliver the benefits. We already have a register and we already have a role in relation to registered nurses and enrolled nurses. I guess what we do not have is a national register, if you like, of personal carers or assistants in nursing.

I think the point that they made before—the previous witnesses—was actually quite good. In practice it is very difficult to identify who would be included and who should not be included in that. I can go back to when the Commonwealth introduced the criminal history checks in relation to the aged-care sector, and the endless debates about who should be included and who should not be included. It got down to things about whether they were a contractor, whether they were in the facility, whether they were actually providing services unsupervised or whether they were being supervised and how much they were being supervised. So in principle it seems to be a good concept but I think that in practice it would actually be quite difficult to manage.

Senator POLLEY: You referred in your submission to us that there was some concern about the government's support mechanisms for the development of the workforce that have been removed. Can you elaborate any further on that?

Mr Kraak : Yes. The issue for us is that what we see from the health side of things is particularly the challenge about the clinical decisions that are made at an aged-care facility. In essence, if a clinician is unable to support a particular person in the aged-care facility or does not feel that they have the confidence and skills to actually do so, the natural response is, 'Well, we need to send them to hospital.' That may be appropriate in certain circumstances. In some circumstances it is not always appropriate, and there are a lot of things that actually drive that particular behaviour. Part of it is knowledge, skill and confidence. Also part of it is the level of clinical support that is available to clinical staff within aged-care facilities. And some of it is actually driven by likely consequences if there is an adverse event in relation to that particular resident—what might actually happen in compliance action that might be taken by the Commonwealth or, indeed, potentially complaints from family members who are unhappy with the decisions that were made at the service.

Senator POLLEY: You were speaking earlier about the NDIS, and there were some challenges there because, if we are looking at carers, there is going to be competition. What impact do you see that is going to have in regional areas of your state in terms of having an adequately skilled and trained workforce and willing people? Is there a possibility of them going across from NDIS to aged care? Do you think that is going to work?

Mr Kraak : I think that is what will happen, and I think that potential options for employees will actually drive a lot more movement to the sector where they believe that they will receive the best remuneration and the best support mechanisms and the best employment conditions. So it will actually expand the potential pool. I think it creates great opportunities, particularly in rural locations. But, to do so, the concern for me is that they are sufficiently trained and supported to deliver the care that is actually required. There is great opportunity, I think, in terms of sharing some of the training and the arrangements between both sectors. There is a degree of commonality between both that we should not see as a competition but see as an opportunity to actually build a more agile workforce that potentially can move between both sectors.

Senator POLLEY: In four days' time, the changes to consumer-directed care come into effect. Therefore, as a consumer, I can choose whatever provider—or multiple providers—I want to deliver the services that I want. From your perspective and from the health department's perspective, is your state ready for this change, particularly in the regional areas?

Mr Kraak : Queensland Health is a very, very small provider of home care packages, so the issue about whether the other aged-care providers are ready would be a matter for them to state. I do think it is a significant change in terms of how services operate, and I do think it is actually going to create a degree of uncertainty for providers in terms of their staffing. The risk that that uncertainty will potentially create is that they will be less likely to want to make long-term employment decisions, potentially resulting in more part-time and more casualisation of services. I have mentioned a little bit about casualisation and, if I can comment on that, that is not to say that using a casual workforce is not good, but there is a balance that has to be achieved. Prior to working in Queensland Health, I worked for the Commonwealth Department of Health and Ageing in aged care, and there was a very close link between high levels of use of agency staff and issues in relation to quality, and it stands to reason. Aged-care facilities and community services have their systems and processes in place. You get someone relatively new to work who may not necessarily be familiar with those processes and it creates a degree of risk, and whilst it is important to be able to have access to agency staff there is significant risk to maintaining quality if there is an over-reliance upon it.

Senator IAN MACDONALD: You are Brisbane based?

Mr Kraak : That is correct.

Senator IAN MACDONALD: Is the residential home you have here in Townsville, Parklands, one of a few that Queensland Health runs? Is that what you are saying?

Mr Kraak : That is correct. Queensland Health has 17 residential aged-care facilities and operates 32 multipurpose health facilities. The 17 are scattered across the state. There are a few in the south-east corner and, going up the coast, there is one on the Sunshine Coast, two in Rockhampton, one in Townsville, one at Charters Towers and a number west of the Great Divide.

Senator IAN MACDONALD: I am not being judgemental about this at all. I am just asking you this to see if you can make a comment or offer a solution; perhaps it is too big a question to ask you. You would have heard both the previous witnesses—and I know that others who are coming later will say the same—about trying to compete with Queensland Health for staff. I think the witnesses indicated that he was paying nine per cent above the award but he was still 11 per cent less than what was paid to Queensland Health staff doing the same job. They are community-run, not-for-for profit organisations. In one case, there was a for-profit organisation that barely seemed to be making a profit. Is there a solution to it?

I guess the solution is that these community ones and the profit ones should be paying the same as Queensland Health; but, again, you heard the evidence, this would mean that many of those community ones, particularly in more remote parts of Queensland, would just shut down. This would then mean that all the residents would have to come into a big city like Townsville. Is there a solution to it? Governments can pay additional wages, because governments just take the money from the taxpayer. Is there a serious solution to it at all?

Mr Kraak : It is a wicked problem. At the end of the day, only about 50 per cent of our income to pay for our aged care facilities actually comes from residents fees—

Senator IAN MACDONALD: About 50 per cent.

Mr Kraak : 50 per cent—and from the Commonwealth.

Senator IAN MACDONALD: Sorry, 50 per cent comes from the residents or the Commonwealth, which means you pay—

Mr Kraak : Which means we pay the balance. We pay almost half to operate our residential aged care facilities. There are a couple reasons for that. Firstly, yes, we do pay more. We do have our staffing mix. We do have a very different staffing mix in our residential aged care facilities. That is partly driven—more so in the metropolitan areas—by the fact that we only provide care to those people that effectively the non-government sector will not accept. The previous people providing evidence identified dementia as a significant issue. For example, even in Townsville, we have a secure unit, which is specifically targeted to support people who have particularly challenging behaviours; it is same in Charters Towers. The same facility is down in Brisbane. The people for whom we provide care have significantly higher care needs—it is not just behaviour; some of it is specifically around complex clinical care—which actually does not make it viable. If we did not provide care for them, they would probably remain in a hospital, which is an inappropriate facility.

At the end of the day, and taking in an even bigger picture, Queensland Health is around 30 per cent of the state's expenditure in relation to health services. It is a $15.2 billion department. There is pressure from all parts of the sector. There is pressure in relation to emergency departments. There is pressure in relation to elective surgery. What we spend on aged care has an impact on other parts of the sector. There is a drive to make it as efficient and as effective as possible.

Getting back to your question: is there any solution to it? Parity would be preferable but to achieve parity would be a substantial, significant investment for the Commonwealth. There is also the image that I think aged care struggles from. So it is about improving that image and improving the actual clinical scope that staff have to cover. For example, we have seen the reduction in relation to registered nurses in real terms over the last decade, which means that their level of supervision and the number of residents that they have to supervise is substantially larger and probably not within the level of clinical support that they have. One of the benefits that Queensland Health actually have is a career structure. We have nurse unit managers, clinical nurse consultants and registered nurses providing clinical support. They are also linked into hospitals and can access the clinical services that are needed. The aged-care industry does not have that. I think those are the sorts of things that would make the aged-care sector a bit more of an attractive service to come to.

Senator IAN MACDONALD: Thanks for that, Mr Kraak.

Senator WATT: Mr Kraak, it is good to see you again after all these years.

Mr Kraak : You too, Senator.

Senator WATT: I was just going to further explore the issues you raised about the NDIS. I appreciate what you are saying in that Queensland Health is a relatively small employer in this space. I am aware that there are already concerns not just in Queensland but across the country about whether we are going to have the workforce required to deliver the NDIS and the increased demand for services that it is going to generate. From what you have said today, it sounds like it is possible that the NDIS might drag people away—or there is going to be competition for people, if you like, between aged care, which has already got its own workforce issues, and the NDIS, where there are some question marks about workforce. What are you seeing being done, whether it be at a national level or anywhere, that is trying to address that double whammy, if you like?

Mr Kraak : To be honest, I think both sectors are working independently of each other. There was a hope when aged care sat within the Department of Social Services that there would be a bit of a commonality given that it sat in one department. Certainly from what we have seen, the NDIS has been very slow to roll out. In Queensland the number of people who have moved into the NDIS has been lower than expected. A lot of the providers who are delivering the services are the same providers who were delivering disability services previously.

The issue for the National Disability Insurance Agency is that they seem to be very much focused on rolling out the scheme. I think there is an acknowledgment that they have some challenges in relation to attracting and building the workforce that they need, even starting at that initial assessment phase. The usual process for the NDIA is that a person makes an application to the NDIA and they determine whether they become a participant and then they approve their plan. Many of the issues at the moment arise before they get to the approval of the plan. There are two: one is to identify them and the other is to make the assessment about what is reasonable and necessary for their care.

I have to say that I am aware of the particular challenges that the aged-care industry has had in terms of attracting a workforce. That has been a particular issue for a long period. Whilst the NDIA and to some extent the Department of Communities, Child Safety and Disability Services in Queensland have been making efforts in terms of participant and provider readiness to ensure that the existing providers are ready for the NDIS, those providers at the moment are to some extent sitting back and waiting for what the demand is likely to be for them as a provider and deliverer of services. So they are very cautious about making significant employment decisions until such time as the NDIS gets more established.

Senator WATT: I think I am right in saying that the aged-care sector, certainly in Queensland and possibly across the country, places a fairly high reliance on temporary overseas workers. I know that you are a relatively small provider, but to what extent do you see that happening in Queensland?

Mr Kraak : I cannot comment specifically about that other than that the Commonwealth is planning to increase its immigration over the next few years, and selecting people who are able to work in social service industries is probably an important component in terms of considering those immigration decisions.

CHAIR: Can I go to a couple of the points you made in your submission and raised in your comments about your concern about the deprofessionalisation of the sector. Can you expand a little bit on that in terms of what you mean and what you suggest we could do about it?

Mr Kraak : I think we referred to the deprofessionalisation in the submission to the National Institute of Labour Studies. That identified over a number of those surveys that the number of registered nurses and, to a lesser extent, the number of enrolled nurses have reduced over a number of years. They have been replaced with personal care workers, many of whom have a certificate III in aged care, which is fine. Our issue, by and large, has actually been that residential aged-care facilities are looking after very frail old people, many of whom are at the end of their lives. The last statistics that I saw was that around 50 per cent pass away within six months of entry to a residential aged-care facility, whilst the average is around 150 weeks, so the remaining 50 per cent remain in those facilities for a longer time. So by virtue of the clinical needs of these residents it requires a degree of clinical skill. It is important that we have aged-care facilities as home-like environments, but they still require some clinical decision making to occur regularly throughout the day and 24 hours a day. If they do not have a clinical workforce there to actually be able to make those decisions the consequence is: if they cannot get a doctor at night the decision will usually be to move a person into hospital, which may not necessary.

CHAIR: There have been a number of submissions from around Australia about the need for having an RN on 24/7. Would you support that? I understand what you are saying around the need for clinical care. In terms of the training of care staff, as we have heard around Australia, I think it is fair to say that most providers have said, 'When cert III is written on a CV we can't necessarily trust that, so we have our own training when people come in.' So the next question is: is it the same here? And following on from that, what do you recommend we should do about it?

Mr Kraak : Firstly, should there be a qualified nurse 24 hours a day, seven days a week in an aged-care facility? The short answer is yes. The nature of aged care is such that you need people available to make those particular decisions. However, I would qualify that a little bit further: it is not just about a physical person being there; while there may well be a registered nurse available 24/7, they may also be covering the retirement village and they may also be covering serviced apartments nearby. So the issue is: what is their scope? How many residents of an aged-care facility are they meant to cover? It is probably a bit simplistic to say, 'As long as you've got one, it's okay.' If you have a 300-bed facility, then most reasonable people would say one is not going to be enough given the nature of the clients.

Senator POLLEY: There would have to be a ratio then?

Mr Kraak : You would have to start thinking about that if you were mandating it. My recollection of the provisions within the Aged Care Act is that in specified care and services there is a requirement to have a qualified nurse. It is already a requirement, but it does not give you reference to the scope if you are wanting to manage it. I guess the Commonwealth manages by looking at access to care and outputs. You had another question.

CHAIR: The next one went to carers and adequate training for carers.

Mr Kraak : One of the benefits of Queensland Health is we have a fairly robust training program ourselves, so we are not necessarily reliant on what actually happens in a particular certificate. We do have an ongoing education program and most of our residential aged-care facilities, if they do not have one educator they have access to an educator either on the campus or in conjunction with other aged-care facilities. My view is that education is key. Relying on just the vocational education sector or on the university sector is not appropriate. It should not be solely reliant upon them. The aged-care industry does actually need an ongoing education program.

One thing I would hark back to is that a number of years ago the Commonwealth actually funded an organisation called, from memory, TARCRAC—Training and Resource Centre for Residential Aged Care. It was funded through a number of universities; in Queensland I think it was through the Queensland University of Technology. Really it was a resource centre that provided resources, made them available to aged-care facilities, in relation to a whole range of different modules. This was when standards were first introduced into residential aged-care facilities, and it was very important in skilling staff and helping them understand not just their role within the facilities but also the philosophy behind aged care. It covered important things around residents' rights and carers' rights and the rights and responsibilities of residents, as well as some of the more practical things that they provided.

One thing I can also say is that Queensland Health have certainly made available a lot of our resources. There were comments before about palliative care. We actually fund Centre for Palliative Care research and education to provide resources and make those resources available. The state is willing to share the resources that it develops and provides to the aged-care industry to support them, but certainly some coordination and consolidation of those resources at a national level would be beneficial.

CHAIR: My final question relates to dementia. You said Queensland Health tends to take those people with complex behaviours associated with dementia.

Mr Kraak : Challenging behaviours.

CHAIR: This committee has done an inquiry into dementia and we have looked at some of the leading edge training and care models. Where are your facilities at in terms of looking at those less secure, not relying on locks and keys for dementia care, looking at making sure we are not using a lot of restraints et cetera?

Mr Kraak : Certainly there is a particular focus on using restrictive practices as a last resort. Having said that, though, there is a primacy in relation to maintaining safety of those residents in those particular facilities and also the other residents within those facilities. There has been a particular focus on trying to minimise restrictive practices where that is possible. The clients we tend to take are the ones who are usually aged and have what we would term as psychogeriatric conditions. They will tend to be the ones with probably the more extreme challenging behaviours. There has been quite a lot of training provided to staff in terms of behavioural management techniques to avoid actually using restrictive practices where necessary and to ensure that it is actually a last resort.

Senator POLLEY: Just a question on notice, because you admitted that you came from the Commonwealth department. I would be interested to have your views on how we can incorporate into the workforce career advancement for those people, so that we keep the good people in the system, and how we can recognise people financially for their skills when they have taken on extra study such as around dementia and palliative care. If you could take that on notice and give us your ideas about where we can take this workforce that would be appreciated.

Mr Kraak : Sure, happy to do so.

CHAIR: Thank you for your evidence today and for your submission. It is much appreciated.

Mr Kraak : My pleasure. Thank you.

Proceedings suspended from 10 : 01 to 10 : 20