[Start of transcript]
WELCOME – Distinguished Professor Xinghuo Yu
Good afternoon, everyone to our RMIT Distinguished Lecture. I'm Xinghuo Yu, the Chair of RMIT’s Professorial Academy and the host of today's event.
Firstly, I would like to acknowledge the people Kulin Nations on whose unceded lands we are meeting on today and respectively acknowledge their elders past and present.
So, today we shall hear from Distinguished Professor Sara Charlesworth who will deliver her lecture on Ageing Futures: quality care and decent work. This is part of the activities hosted by the Academy to fulfil its obligation as ambassador, advocator and thought leader for RMIT.
Before we start, let's just get through some housekeeping matters. This is a Teams Live event; you will not be able to directly ask any questions by microphone. please post your questions in the Q&A section during the lecture, and at the end of the lecture I will pick up those popular questions to ask the presenter on your behalf until our lecture time is up.
So, let's just start the lecture by introducing the speaker. Distinguished Professor Sara Charlesworth research is on gender inequality in employment, and its various manifestations, including in gender pay, equity, sex, discrimination, gender-based violence, and the and precarious and insecure work. More recently, her research has focused on aged care sector. She has participated in key gender equality policy reviews and debates and been invited to give evidence to a range of government inquiries including to the Royal commission into Aged Care Quality & Safety. She has also been an advisor to diverse government and private sector organisations as well as community and human rights bodies.
So, without further ado, please join me to welcome Sara to deliver her lecture. Over to you, Sara.
LECTURE – Distinguished Professor Sara Charlesworth
Many thanks, Xing. And also like to acknowledge and pay my respects to the Woi wurrung and Boon wurrung language groups of the eastern Kulin Nation on whose unceded lands I'm currently located. And indeed, and thinking about better aging futures, we can learn a lot about the recognition of many older adults by First Nations peoples as elders, as people to be held in esteem and as wisdom holders of the community, rather than a problem to be dealt with away from prying eyes.
So, the Royal Commission's emphasis on caring as a relationship goes to the heart of good quality care. Today I'm going to focus on current and future challenges in creating and sustaining caring relationships in aged care, or what is known as long term care, and draw on recent research to address to address two key challenges.
They are of ageism and the gendered undervaluation of aged care recipients and workers and ensuring that we have the necessary policy and regulatory architecture as well as work conditions and work organisations, work organisation to provide the conditions for quality care and decent work. I’ll also talk briefly to the growing migrant aged care workforce in aged care.
So, I'm drawing here on two main projects, the Decent Work Good Care project is a cross national study for aged care systems and as well as policy analysis and interviews across the four countries. I draw in particular on data gathered through a rapid ethnographic methodology. Our version of this methodology made use of between 2-4 4 insider researchers who had national expertise in the particular country and two to four outsider researchers who had expertise in other countries systems. We use this in organizational case studies conducted over an intensive period of up to a week on the ground and gathered data from multiple sources, including through observations, shadowing workers, interviews, informal discussions, etc, with managers, workers and our clients and residents.
The Markets, Migration and Care project, led by Emeritus Professor Deborah Brennan, was essentially a multi-level policy and regulatory study of the ways in which migration, employment and care regimes intersect in Australia and New Zealand to shape in particular the migrant care worker experience. Today I draw in our analysis of migration regulation in the Australian context and analysis of available data sets.
And really, the central theme of these two projects has been exploring ways in which care quality in the formal aged care system can be undermined, or indeed enhanced by the conditions in which frontline workers provide that care.
Researchers interested in the impact of employment care and migration regimes on the conditions of work, and care have focused on the complex interplay of institutions, policies, regulation, national and global conditions, and policy mechanisms that intersect in different ways in different national contexts. And as I will highlight later in the lecture, gendered norms about what constitutes skilled in aged care are reflected in all three regimes.
In Australia as elsewhere, Covid really revealed the fault lines in our age care system. And across the board, it's revealed the lack of dignity and respect accorded both aged care service users and workers in planning for the pandemic.
There was a lack of adequate equipment and infection control training. A lack of clarity about accountability of federal and state governments, the safety regulator, and providers. And the price of increasingly fragmented and precarious work with the lack of or limited access to paid leave became very obvious in terms of the workforce.
While the rate of covid infections and the death toll of aged care residents was regularly reported on in Australia, there was really relatively little recognition of the impact of covid on workers except by the Royal Commission into aged care, quality, and safety.
So, we see in this excerpt here. The Royal Commission undertook a special inquiry into the impact of covid, and in that report in the introduction, they actually draw attention to the impact or some of the direct impacts of covid on aged care workers which I think is very important and once again they underscore the importance of the close relationships that care workers developed with residents in this case, but it also applies to home care.
In Australia, if you can see here in the circle, that this is data actually on worker cases and deaths, and from a number of countries. The number of covid infections recorded for workers in residential aged care, in fact slightly exceeded the number of covid infections among residents, but you wouldn't know that from the media.
However, luckily, unlike in particularly the US and the UK, in Australia, residential aged care workers didn't die of Covid contracted at work. However, despite the fact that there are many more older adults or not come to this using home care services home care clients and homecare workers have not only been absent from most discussions of covid in aged care, but also in discussions of the future of the aged care workforce. So, in this talk I want to focus mainly on home care in an attempt to bring this vital and indeed growing sector of formal care into view.
But well before the COVID pandemic started, the Royal commission to age care, quality and safety recognized in its interim report the systemic substandard care in Australian aged care. And they note here key fundamental contributing factors to both unacceptable quality of care provided and also underscore the role unacceptable conditions of work play in the poor quality of care we have in our system in Australia.
At the Royal Commission, 85% of witnesses spoke about workforce issues. And I'm going to attempt to pay you two very short excerpts, one from nursing home resident Merle Mitchell, who unfortunately died a little while ago, and a worker, Kathryn Nobes, who both talk about the impact of an adequate staffing on the quality of care.
[9:07 Video audio]
I'd like to take this opportunity to revisit some of the evidence you've heard from a selection of our workforce witnesses so far. To do so, we ask the operator to play a video.
Staff don’t have time to provide that sort of support so if I need something in the middle of the night, because there's only one nurse responsible for 170 patients, I wait up very, very long time.
And I'm just going to take you to the worker here if you could bear with me. This is Kathryn Nobes.
[10:03 Video audio]
In my opinion, there was insufficient staffing at the facility. We are told that everyone is individual and has to be treated with respect. As keyworkers, we completely agree with this statement. However, we repeatedly found ourselves with such a heavy load workload that we just have to manage this situation that we can't give the residents the time that we would like.
So, these two excerpts, really, I think, give a flavour of the lived experience of key care recipients and workers in our system of our age care and I think the particularly the latter one underscores the disconnect between the rhetoric of person-centred care and the actual reality on the ground.
So, I want to step back now a little and provide some background to our formal aged care system because in fact it plays a relatively small part in meeting the support needs of older adults.
Most older people who require support with the activities of daily living had that support provided by family members, overwhelmingly female partners, and daughters. Now, as you can see here, with population aging and increasing longevity, as people age large, there's a large and growing proportion who suffer at least one long term health condition.
This brings with it a complexity of needs for assistance with the activities of daily living as people age, especially personal activities with the greatest need overall for assistance with health care and mobility. And particularly for those aged 85 and over the need for assistance with self-care and cognitive and emotional tasks also rises sharply.
So, who uses long term care in Australia? In 2019-20, over one million people received support from formal aged care services although some people used multiple programs more than once during the year. But as you can see here many more people used homecare than residential care.
The Commonwealth Home Support Program is used by the most service users and it's a program that's supposed to provide entry level services and, importantly, is block funded.
A smaller but growing number of people now use the Home Care packages program, which has a consumer directed model of individualized care where a fixed amount of money per annum is provided for individuals for care and support on the basis of their assessed needs. Now this program was roundly critiqued by the Royal Commission as it's highly rationed, inflexible, and inadequate.
There are 100,000 people still waiting for a package who had been assessed and approved for one. And last year 16,000 people died while still waiting to be allocated services for which they've been approved.
From the data here from the Aged Care Finance Authority, you can see the importance of the use of aged care services by women and over across the board women make up two out of every three service users and the use of services by women increases with age.
This actually puts our use of long-term care in cross national perspective and as I said, if we focus perhaps here on the figures, I've highlighted the most long-term care is used now by our people 80 years and over. Institutional care is residential, What we know is residential care in Australia.
But in most OECD countries including the ones here, a greater proportion of our age care recipients use home care rather than institutional care.
And as you can see, Australia's use of residential aged care for the 80 plus population is higher in other countries. The shift to home care is much more advanced, for example, Sweden and New Zealand, as you can see there.
In its final report, the Royal Commission set out what the community expects from aged care in Australia. But this is a long way from the reality of what the community actually gets.
Government policy could arguably be, could be argued to be essentially based on a palliative model. And to put it crudely, it's about keeping people comfortable till they cark it.
Aged care policy can be compared with the policy aims of early childhood education and care and the National Disability Insurance scheme where at least the policy focus, if not the practice, is much more on supporting service users to realize their potential; there’s no mention of in Australian aged care policy.
But the community also gets is the real lack of accountability and this has been missing in action through successive federal governments and by providers particularly in accounting for the funding spent on the provision of care and there is really very little quality and safety oversight of the care that's delivered particularly in home care, as the Royal Commission notes here.
What results then is rationed, task based, rushed and substandard care.
So, what underpins the parlous state of our age care system?
Ageism is an important norm and this 2019 submission to the Royal Commission from abroad based National Coalition points to the important role of ageism which attaches a lower value and greater stigma to old adults, particularly those with long term health conditions or disability and that's very much reflected in our systems of aged care.
The ageist engendered undervaluation of older service users, who, as I've already explained are increasingly female as they age, and the gendered undervaluation of the work performed by the frontline aged care workers lie at the heart of our current system.
So, who works in age care?
You'd have to say that the quality of available data on the aged care workforce is a national disgrace, and that's for two main reasons. The level of accurate detail available and the reliability of that available data, and the inadequacy of data really reflects the lack of attention historically given to this important and growing sector of the economy.
In terms of Australian Bureau of Statistics starter, there's a lack of adequate disaggregation of industry classifications, particularly in home care, and also the occupational classifications set out are also use very poorly described are descriptors.
These classifications underpin available sensor starter. This makes it very hard to accurately identify the key characteristics of home care workers, and in particular the classification of home care workers has aged, and disabled workers may well include disability support workers who work with clients in private homes also.
The second set of data, the independently run four yearly national Aged Care Workforce census and survey data and the last one was produced in 2016, has been used as probably the best source of week of data we have on the age care workforce. But they were only run with directly employed workers who are a slowly declining share of the frontline care workforce, both with the rise of care workers employed in as self-employed in labour hire, or indeed as gig workers.
The so-called age key work for census that was run by the Department of Health in 2020 was run with providers only. They surveyed program by program and they say themselves that their worker numbers are probably overestimates as workers may be counted more than once working across a number of different programs and sights.
But what is clear from all the data sources is at the front-line age care workforce is overwhelmingly female and indeed an older group of workers with an average age of between 45 to 49.
From the NACWCS surveys, there is an evidence of a declining ratio of workers to recipients at the very time the needs of the older adults who use the system have become more demanding and complex. The NACWCS survey also show that over time the skill mix and long-term care has declined. There's simply a smaller, much smaller proportion of nursing qualified staff in 2016, than there was in 2003.
In Australia there are no mandated staffing levels or skill mix, unlike in early childhood education and care. Our quality standards only require staffing numbers are adequate and skill levels are appropriate and what that is left up to providers with really very little oversight by the quality and safety regulator as both the Royal Commission and also Professor Gabriel Maher from Macquarie have noted.
So, what do home care workers do?
This answer classification that you can see here really mischaracterizes the nature of home care work. It's classified as ANZSCO level 4, which in the ANZSCO classification typology is low skilled work, but in fact homecare workers provide a range of complex care and support by themselves in a client’s home with no direct supervision. This requires high levels of responsibility and judgment. There are distinct areas of skill where workers exercise knowledge acquired in formal training and through experience to carry out care work with a frail aged.
It's very different working with clients who are unable to undertake certain care for themselves but able to make decisions about their care they need, than with clients who are unable to make decision about their care at all. And this is an important distinction that's made in the much better homecare classification structures in Victoria, and local government are home care services.
Going to skills in home care, I draw here on a typology from Professor Lydia Hayes from Kent University, who identifies a series of types of skills, but if we look first at home health or nursing related skills and knowledge of complex conditions, some examples in home care for those concerned with what were described in the former New South Wales Award covering workers and the now defunct New South Wales Home Care Service as bodily and intrusion skills. These are assisting with bowel use, pig feeding wound management, catheterization changing colostomy and drainage bags.
Home care workers also need knowledge of how to manage client behaviours related to dementia or cognitive decline and also provides sensitive end of life care. Body works skills require specialist knowledge and skill to enable appropriate care for the different bodies of service users. Such as skills needed to monitor and protect skin integrity, adhere to hygiene and infection control policies, and maintain the dignity of the client.
For example, knowing how to undress, shower and dress a frail 90-year-old who was very stiff limbs in a way that's comfortable for her preserves her dignity and observes her preferences for how she likes it to be done requires skill.
Relationship building and high-level communication skills are also used. For example, building trust and ensuring clients dignity. Providing personal centred care, person centred care and enablement, and supporting different clients who may be experiencing emotional physical difficulties or conflict with family members.
Where domestic work meal preparation and shopping is provided, it's really just housework as a lot of people tend to think it is. It requires the capacity to adjust round very diverse clients’ needs and preferences and working with clients who may be very difficult or aggressive, or indeed reluctant to eat at all.
However, in this point is really important, the exercise of skills takes time. In the decent work Good Care project, we found that even in good providers that there's often insufficient time for the practice of skills held. The allocation of adequate time to care is crucial to the optimum use of both existing and acquired skills, knowledge, and competencies.
I'm now going to turn to some examples of care work that's provided by our age care workers.
So, in this example this field work, field work notes taken during the shadowing of a personal care assistant in a dementia aged care unit.
Most residential aged care have dementia units which where those in the most advanced stages of dementia are typically located. And this excerpt illustrates just one example of a tiny Filipino worker realizing the growing agitation of a much larger man and she's moving to try and deescalate his distress.
Selena had been helping a group of residents eat their dinner that she had to stop to address the situation with Alan’s distress and on her return she then had to work at speed to try and catch up, but in doing so she rushed several residents through their meal, which wasn't at pleasant experience for either them or her.
This excerpt is from an interview with a home care worker working with the palliative care client. She's describing the massage that she provides this woman in palliative care. So apart from the important body work she's performing, the time she's allocated is inadequate and now there is a process of negotiation to try and get that time increased which will incur an extra cost out of the home care pallid, package, allocated that client. However, until that's sorted, Helen like so many aged care workers ends up having to perform some of the care needed on her own time and this is something you hear incredibly frequently from age care workers. They're very reluctant to stop work simply because the time allocated to perform a certain task has run out.
The one certainty in aged care is that residents and clients die. In this excerpt from field notes at a home care organization illustrates the toll on workers.
While some services expressly forbid workers to attend the funeral of clients, at this organization workers who have been the primary care are allowed to do so, but they're typically have to attend their client's funeral on their own time.
What is striking in aged care generally, and this has been in all the aged care systems we've had a look at is the lack of system wide or organizational wide formal support or supervisory practice that might support workers through the death of people with whom they're formed close relationships.
I'm now going to turn to some key conditions of work, focusing primarily on wages and working time conditions.
So, in this table here, while obviously the pay rates for home care workers is higher in Australia in all jurisdictions entry level pay rates sit only just above the applicable minimum wage. And these wages are very low given the skills, level of responsibility and judgment required that I've described.
In Australia, any increase in wages for home care workers has only been achieved through the flow on from national minimum wage decisions. To date there hasn't, although there's currently one on foot, there hasn't been any revaluing of the work of home care.
Within the relevant award, there are three levels for our frontline homecare workers pay classifications are very rudimentary compressed, and there's just $1.60 per hour difference between the entry level and the top level at level 3.
The award not only fails to provide meaningful progression in terms of pay, but the skill classifications linked to the three levels also lack any relevant description and specification of the skills actually required in home care jobs, including at different skill levels and I've already alluded to Victorian local government and the now former NSW Home care service. But both those home care services do have decent skill descriptors and meaningful differences in pay rates between different levels.
Despite numerous government enquiries and the Royal Commission establishing the detrimental impact, low wages have on the attraction and retention of aged care workers, there has been an historical disregard and lack of accountability by successive federal governments for ensuring decent award rates in a sector for which it is directly responsible. The federal government is effectively the lead employer in our age care, and this works to limit and normalize the low wages in the relevant awards.
This disregard also reflects and reinforces a dominant sector logic or narrative that good, aged care workers are not overly concerned with low wages and poor working time conditions because they find meaning in their work. Which they do. But it's hard to imagine that similar assumptions will be made about government infrastructure spending in relation to workers in the male dominated defence support industry.
And now I want to have a look at just some key deficits in working time conditions and one of the most egregious is the lack of working, paid working time. So unlike in New Zealand and the UK, there's no employment provision in Australia that requires that home care workers be paid for the time they spend traveling between clients.
It's hard to think of any other Australian sector where an inherent requirement of the job that is traveling between clients would remain unremunerated.
Another key deficit is the on-demand work organization that typifies the sector. So casual contracts or permanent part time contracts with low numbers of guaranteed hours leave workers wanting more hours of work to provide sufficient income on which to live which creates underemployment.
In 2016, 40% of home care workers wanted more hours of work than they currently had, which is reflected in high rates of multiple job holding, which at 16% was three times then that for the total workforce at that time.
The other big issue is the way that short hours can be fragmented across the day. So, the relevant award not only allows casual workers but also permanent part time workers to be employed on very short hours that can be broken up over the day. This is the time and task based oriented allocation and charging for care services under the Home Care packages program has worked to further fragment working time conditions for home care workers which directly affects the quality and continuity for both clients and their workers. So central to building a care relationship. And the rates of staff turnover are particularly high in this particular program.
The award also provides employers with the capacity to flex permanent part time workers hours up from and down to their contracted hours at ordinary time rates, which creates considerable employer flexibility without having to pay a casual loading.
And this flexibility arguably acts as a disincentive to provide longer minimum part time hours to home care workers, which is the expressed preference of many in the sector. In many ways, designing work that creates this unused labour potential as perplexing as the sector is continually crying out for more workers.
Another widespread employer practice in Australian home care, it's not really found elsewhere, is requiring workers to nominate their availability beyond their contracted weekly minimum hours. That is, in order to be guaranteed a certain number of minimum weekly hours, workers have to be available for additional hours to that minimum. So, this practice of availability operates and on call mechanism, whereby an employee can be called and expected to cover shifts at very short notice. There's no additional payment for this availability and where worked, these additional hours are paid at ordinary time, not casual rates.
How availability works in practice is illustrated in the following excerpt from an interview with the person in charge of rostering at one of the home care sites, the Decent Work Good Care team spent time at.
So, the schedule is really describing what happens when they've got to cover 5 clients because a care worker has called in sick, and so while in theory the award requires mutual agreement to working additional hours, a workers nominated availability outside their contracted hours, in this case, the worker has said that while she normally starts at 8, she has agreed to be available from 7. It's simply assumed that she will be available and she in this instance she gets a call at 6 and being told, sorry you've now got to visit Nancy at 7:00 o'clock.
S, it really provides this function of availability really provides for just in time rostering changes.
I'm now going to turn briefly to the migrant aged care workforce for two main reasons. As I said, they form a large and growing proportion of the workforce, and providers are increasingly calling for temporary migrants to fill vacancies and to fill what scene is increased demand in the sector.
Migrants migrating expressly to work and what are deemed as low skilled occupations would normally be excluded under current Australia's migration regulation and transition from temporary to permanent status is only possible for skilled jobs, those jobs that are classified at ANZCO Levels 1 to 3, not for people who are in frontline care positions which are classified as ANZCO Level 4.
However, the government has recently extended the Pacific Labour scheme to so called low skilled workers and has very recently bought in 32 workers on temporary visas from the Kiribati to work in aged care in rural and regional Queensland, and this scheme is being expanded and is essentially an employer sponsored scheme where workers from Pacific Islands will work in rural and regional Australia.
So, this chart is to really show that while we don't talk or recognize migrant workers much in Australia, but compared to many other countries, we have a far greater proportion in our aged care workforce. And yet the issue of migrant care workers is as I said, the focus of very little policy or academic attention here, even from the Royal Commission.
One reason may be that many migrants working in aged care a permanent residents, unlike in some other countries. And until the tightening of migration regulation in 2009 with the shift to both temporary visas and tightened skill requirements, many of those currently working as frontline aged care workers had arrived as permanent migrants on family humanitarian and even skilled visas. However, overtime the countries where migrants now work as aged care workers, the countries where they were born has shifted dramatically to those from non-English speaking background countries. And while important post war, the United Kingdom and also New Zealand have declined as the main country of birth of our migrant workers, particularly in residential aged care.
And over the last 15 years, there's been a rapid increase in the proportion of migrant care workers from India, which you can see reflected for both in residential aged care and home care. And entrants from Nepal have also grown while entrants from the Philippines have remained pretty constant since around about 2010.
The characteristics of recent migrant starter which I'm using here is a Labour force survey and unfortunately we can only get reliable data at the aggregate care worker level rather than just aged care worker level. But it does provide information on migrant care workers who arrive between 2006 and 2016 and tells us what type of visa they held on arrival and as at 2016.
And as you can see here among workers who arrived during this period the top five countries of origin are India, the Philippines, Nepal, Sri Lanka, and Bangladesh and together those five countries of birth are around, will account for two thirds of our recent migrants.
But as summarized on this chart here on arrival, almost 2/3 of our care workers in the last columns that you can see here were on a on a temporary visa, however those from the top five countries were far more likely to enter on a temporary visa than those from other countries.
The date of arrival also appears to connect to the type of visa held on arrival. So, in the first period from 2007 to 2011 we can actually see there's a higher ratio of permanent visas, however in the second period we can see that a much greater proportion of people who arrived during that time arrived on temporary visas and that really reflects, as I said, Australia’s increasingly strict migration settings.
Now, in many countries, migrant care workers are located in areas of the labour market was poor conditions than their locally born counterparts. So, we decided to see if that was the case in Australia, given we've got the protective factor of mainly permanent migration status among our migrant workforce.
And we've looked at two job quality indicators available in the 2016 National Aged Care Workforce Census and survey, casual status and under employment.
And the question we asked was: do these groups of workers have poor quality jobs against those two job quality indicators than their Australian born counterparts?
And what we found was that compared to Australian workers that home care workers from a non-English speaking background country were the most likely to be casual and under employed. Whereas English speaking background personal care assistants for more likely to be casual while non-English-speaking background personal care assistants were more likely to be under employed.
And when we ran a multivariate analysis and controlled for socio demographic and employment characteristics, we found that being a non-English speaking background migrant was significantly associated with both casual status and underemployment.
Now, because the literature also suggests that time spent in a host country has a mitigating effect on employment disadvantage for migrants, we also had a look at what, at what at what happens are over time.
And I'm sorry I was seeing around to other wrong slides
And our analysis supports the general trend of those findings elsewhere, but paradoxically, over time we found it casual employment in fact increases for non-English speaking background, personal care assistance while under employment increases generally for migrant home care workers.
We also found that holding a temporary visa increased the likelihood of casual employment for migrant personal care assistance and under employment for migrant homecare workers.
While working for a for profit employer which has been associated with much poorer working conditions in some countries like the UK for example was also associated with casual employment and underemployment for non-English speaking migrants, particularly homecare workers.
Now, with the growing demand for an increased age care workforce, it's highly likely we will need to increase migration to meet this demand. However, given our current migration settings, which position age care workers low skilled, the great risk for workers coming in on a temporary visa to work in aged care, which is reflected in the characteristics of recent migrant starter I've just looked at, is what Peter Mares calls ‘permanent temporariness’. Along with the additional vulnerability that workers experience when they're sponsored by employers as in the Pacific Labour scheme, and indeed a similar scheme in New Zealand has found has been identified as creating specific vulnerabilities for care workers who come in through their essential skills visa scheme.
So, I've spent most of the lectures setting out how the care, employment or migration regimes in Australia intersect and produce poor conditions of work in poor conditions of care, and in particular I've drawn attention to the lack of recognition of the skills required and used by age care workers in award skill classifications, and the lack of any meaningful wage increases up the limited skill classifications in awards.
But in conclusion, I want to acknowledge that in our decent work, good care project we have come across examples of good practices by Australian aged care providers. But these practices due in the main to the mission and commitment of this specific providers, such as providing longer hours or full-time work for home care workers involving them in the review of care plans for clients. In one case, higher pay rates through an enterprise agreement, training on paid time are unusual in the Australian context and have occurred in fact in spite of rather than being encouraged by the settings of our current Australian aged care system.
Now I want to briefly canvas extremely briefly canvas one alternative drawing on the example of New Zealand home care.
So, in this observation here, this is really an illustration, this comes out of shadowing home care, a home care worker across 6 clients. And we found that not only was this occurring in this individual service, but that the systems in New Zealand support the building enough time in home care and that through a number of factors.
There’s close government links with an oversight of service providers. So rather than having a centralized system as we have in Australia, very remote system, you have devolved district health boards, there's 22 in New Zealand, and in the better district health boards have introduced a policy called alliancing which is where that board works closely with, in this case home care providers, contracted to provide home care services to a particular geographical area. So, for example in one District Health Board where we spent area, we spent quite a bit of time, there are four home care service, two are for profit, two are non for profit, but the alliancing arrangement means that they have to share their data, they have to share clients and they are able to give direct feedback to the District Health Board through changes in policies. They also very interestingly encouraging much greater use of nursing staff. So, in home care services nursing staff will very readily come out to assist a home care worker where necessary, yet at a client’s home.
So, they're much more responsive services and they provided direct line for worker advocacy, as in this case for a client. So, in this particular case, Butri talks to the registered nurse at her service and says we need an extra time for Sandra because I need to be able to go shopping with her because she's got nothing to eat on the weekends because the Meals on Wheels service doesn't operate on the weekends. We need to make sure she's got enough to eat and that was very quickly put in place.
In New Zealand too, they’ve got a career structure that provides that came through and equal pay settlement, which also provided for paid travel time and it provides qualifications tied to the career structure with meaningful wage increases at different levels of that career structure and providers are funded to support workers gain qualifications.
OK, some key takeaways. Decent work is necessary but not sufficient to produce high quality care. We also need system wide decent systemwide, direct involvement and accountability by the federal government for the quality of care and the decent work conditions to underpin it.
And as I've mentioned, we've had some in this country some examples are good paying skill classifications and working time conditions in New South Wales, in the former New South Wales home care service run by the state government, and we have similar paying conditions now, and a dwindling number of Victorian local governments that these services are not sustainable because of the federal government hasn't adequately funded the cost of quality care. And that's really what we need to provide this system like with feeling.
So, before I end, I'd like to thank the list of collaborators on the two projects of which I've drawn a special shout out for Wendy Taylor, who's managed the very unwieldy, decent work, good project over four years and helped me with these slides.
And also, many thanks to Adelina Onicas who greatly with their design of this presentation, far more elegant than my usual PowerPoints.
I thought I'd end with its lovely image of a worker and a client in the New Zealand Pacifica Home Care service we visited with older adults, are treated as elders. We this very much an action also in their connections with local communities, including with different Pacifica community elders who actually don't use the service.
So, thank you very much. I'll leave it there.
Q&A – Distinguished Professor Xinghuo Yu
Thank you very much Sarah for excellent talk you. When I listen to it. I mean, you know the more. listen you feel heavier, sometimes it's sad that people are not able to look after our aged people better.
So now we are into the Q&A section. We've got a couple of questions.
Here is one for you. So insecure work infects far too many workplace and it is particularly perverse in a wealthy country as Australia. In your experience with the Royal Commission, is there a meaningful discussion on the value of awards and enterprise bargaining agreements as key contractual instruments that set to the minimum platform for decent work in the aged care and like sectors. If there are discussions on foot, what is the general tenor, if not, do you see any reasons for the silences?
Response – Distinguished Professor Sara Charlesworth
Excellent, excellent question, in fact, they've been 20 inquiries into aged care across the last 20 years in Australia, so the Royal Commission was the last one and this has been the only inquiry that actually recommended wholesale addressing of wages and skill classifications. Now it's unclear the extent to which this will be taken up, the federal government says it supports this recommendation in principle. What that means, we don't know. There is currently a work value case being undertaken by the health services union, which is looking at wages only, which is looking at a $5 wage increase for both our home care, well really in home care, and residential care, it's not just for frontline workers, it includes also the other workers I haven't spoken about, the very necessary administrative and kitchen staff and cleaning staff, that particularly work in residential aged care.
Enterprise bargaining has proved quite a disaster in Australia. It’s particularly in the home care, it's very difficult for unions to organize, and the very few enterprise agreements that exist, the wage increases are either exactly the same as in the award or they sit literally cents above the applicable award rate as I said, the one exception apart from a couple of very good, aged care providers and Victorian local government, they are the exceptions to that. Their enterprise agreements provide significant wage increases. So, it's very clear that something has to be done, particularly in the sector and going right back to the beginning quote from the Royal Commission if you're going to have good quality, caring relationships you need a stable workforce to provide that continuity to enable those key relationships to flourish. Without with insecure work and particularly increasing the fragmented way workers organized that's very difficult to achieve.
Question – Distinguished Professor Xinghuo Yu
Thanks, Sarah's, here's another one. What could the federal government do more to promote careers in each care and home care both to those new and experienced in the workforce?
Response – Distinguished Professor Sara Charlesworth
Interestingly without doing anything about wages or conditions, there are some promotion campaigns. There is some work being done by the relevant Age Workforce Council to say look, this is a really good sector of work to come to and that is true. And as I said if you talked to workers, they really do find they’re there not because of the wages or the conditions, but because they view this as important work. What they do mind though is that the community, and indeed the government, doesn't seem to recognize that in ensuring that they're properly paid so, it will be very interesting to see what happens overtime. But it will seriously need to be addressed and when the government does costing for the and there will be an increased cost if we go to have a quality aged care system, it absolutely needs to factor in decent wages and conditions and those conditions go to time.
So, one of the things the Royal Commission has mandated in residential aged care only, is they’ve mandated a certain number of care hours per day per resident, which is going to need increased number of workers.
But why aged care providers don't simply provide workers who are desperate to work longer hours with those hours is the million-dollar question. It seems quite bizarre that you wouldn't make, as I said, he wouldn't make use of this spare labour capacity that's clearly sitting there, but I think that there's a view, particularly we're moving to this home care package system that this is true, as my colleague Fiona Macdonald has written extensively about and the National Disability insurance scheme, the models actually drive the fragmentation of employment. So, we need to be rethinking how can we provide some good employment conditions and still will respond to the needs of individual clients for the care and support when they need it.
Question – Distinguished Professor Xinghuo Yu
OK, thanks Sarah, so here's another one. You mentioned the ageism and the genderism, I'm wondering if you have considered the intersection with racism given your findings regarding the workforce.
Response – Distinguished Professor Sara Charlesworth
Absolutely and very good question and that's certainly come out in workers we've spoken to, home care workers who tend to client’s home and has the door slammed shut in their faces: we're not having an Asian or we're not having an African come into our house, thank you very much.
And because the consumer directed care system now emphasizes choice and control, and so you say to provide us, so what do you do and they say it's kind of up to the client if they don't want this person, well can we force them to have this person? So, racism is endemic I have to say Xing and in residential aged care workers who are not Anglo, visibly Anglo Celtic have a tough time not only sometimes, from Anglo Celtic residents but also from their Anglo Celtic co-workers.
Question – Distinguished Professor Xinghuo Yu
OK, thanks, I've sort of have to jump in on this question because as a migrant who experienced this kind of working environment. So, I'm wondering whether culture has ever considered in the aged care framework, because different culture would see it quite differently would have different requirements. Has any kind of a customization, any sort of protocol or regime for taking that consideration into aged care?
Response – Distinguished Professor Sara Charlesworth
Well look in Australia because we are a migrant country there are quite a few what we would call ethno-specific services so that in fact, the unfortunate St Basil's which is the subject now the coronial inquest because of the appalling handling of Covid was an ethno-specific facility for Greek speaking older people. We know as people age particularly migrants, they often revert back to their mother tongue and then there is the real need for culturally appropriate care, but there's also a need for so-called mainstream services to be provided at, and once again some of the better services will try and do so, but when you spend when services spend so little on food and I'm thinking residential aged care and in some of the better providers we found $6-$7 a day per resident was being spent on food, what you're providing is it's very hard to make culturally appropriate, food. So, this is a huge issue and there are now certainly a lot of policies and the Federation of Ethnic Communities Councils of Australia is very big on this and trying to have more done round culturally appropriate care food.
On the reverse side though, what some migrant care workers will tell you is that they find because particularly from some cultures, they come where elders are respected, they find the way the paternalistic way or the infant, infantilizing of aged care service users as quite offensive and foreign to the way in which they see older people. So that, yeah, there's some real tensions.
Question – Distinguished Professor Xinghuo Yu
OK thanks so we are approaching the time. Here is the last one.
How might we begin and encourage value alignment between providers, care workers and the residents? If policy is weak.
Response – Distinguished Professor Sara Charlesworth
Excellent question and this is why we need strong policy. We need as I said, the government has been missing in action. There's this fantasy that aged care as a market. Now, the Royal Commission interim report clearly said aged care is not a market it can't operate according to market principles.
We need an active, engaged government that actually takes responsibility for this particular, this particular domain and the example I use before of the defence support industry we this is a government are seen as a government responsibility to make sure we have defence capability. It should also be a government responsibility to ensure we have decent care infrastructure because it is infrastructure that actually support people in Australia as they age.
Question – Distinguished Professor Xinghuo Yu
OK, we have two minutes. There's another question.
In your observations of training for care workers, did you notice any existing formal and informal training in dealing with CALD clients?
Response – Distinguished Professor Sara Charlesworth
On, CALD clients. Yes, which is that term people use for people who are culturally and linguistically different. I personally don't like it because it gives impression that the Anglo Celtic is that the norm.
There, yes there is sometimes some training and I know that one of the not-for-profit organization in Victoria, the multi-cultural women's health does quite a bit of training in residential aged care. To try and engender some recognition of culturally appropriate care, it's not there by and large, so the formal care that most workers have done as Certificate III or Certificate IV in aged or community care, some of them done specialties and dementia care.
When the Federal government survey providers at the end of last year at asked them, what provided training it provided a number of them said that it provided diversity and inclusion training. What that is, though, we don't quite know, but I think that they're given our aging migrant populations particularly our post war populations, there are, there's a real need for tat to have that training in place.
Ending – Distinguished Professor Xinghuo Yu
OK, I think the time is up. So, on behalf of the participants, thank you so much for excellent enlightening talk. And for the rest of the participants, I wish you have a good afternoon and looking forward to seeing you in another lecture. Thank you very much.
[Sara] Thank you very much goodbye. Thank you for coming.
[End of transcript]
30 November 2021, presented by Distinguished Professor Sara Charlesworth
The crisis faced across the OECD in the provision of aged care was made visible to the broader community during the COVID-19 pandemic. In making the link between the quality of care and the working conditions of the frontline workers who provide the care, the lecture draws on a body of collaborative research conducted over the last decade.
Funded by the Australian Research Council and the Canadian Social Sciences & Humanities Research Council these different projects provide multi-level insights into the ways in which the interaction of gendered care, employment and migration regimes can produce both unacceptable care and unacceptable forms of work.
These research findings also point to the systemic changes required to ensure that frontline workers have the economic security and time to enable diverse cohorts of older adults to age with dignity.