Australian policymakers have long known they have a major problem with our aged care workforce, and they’ve known what the solutions are. But they’ve failed to act for over a decade, despite constant reviews and studies detailing the challenge. The result has been an aged care system that is an insult to senior Australians, who have been abused, rorted and neglected in their final years and allowed to die in their hundreds when COVID reached our shores.
Only, the problems won’t go away in the lifetime of the people currently in power. On current policy settings, those problems will still be afflicting our aged care system when they themselves need care at the end of their lives.
Worse, they’ll be afflicting every other developed country, not to mention China, at the same time — an aspect generally missed in domestic analyses.
Our main problems in the aged care workforce are that we already can’t attract enough people to the sector now, we’re going to need to attract a much bigger workforce in years to come, we don’t pay either personal care workers or nurses who choose to work in aged care enough, we impose precarious work on carers, and we rely on migration to provide a large proportion of our aged care workforce.
There are other significant problems that bear on the quality of care — the need to professionalise the workforce, to improve qualifications, to lift standards in important areas of geriatric care — but they pale before the problem of actually finding workers.
But many other countries have exactly the same problems. An OECD report from last year finds that in OECD countries “the LTC [long-term care] sector suffers from shortages of workers, and this is likely to get worse in the future … LTC workers earn much less than those working at hospitals in similar occupations … Non-standard employment, including part-time and temporary work, is common in the sector … Over 20% of LTC workers are foreign-born in OECD countries.”
In fact we’ve relied more on migration to provide our aged care workers than most developed countries: 30% of our current residential aged care workforce are migrants (though the the figure is lower for home care workers). Will we be able to rely on migration in the future to meet our expanding needs?
In 2011, the Productivity Commission estimated that, keeping 2008 staffing ratios, Australia would need to grow its aged care workforce from around 320,000 in 2020 to around 720,000 in 2040 (about 78% of that number are direct care workers; the remainder support staff). For the aged care royal commission, Deloitte estimated that the direct care workforce would have to increase from 320,000 to 483,000 in 2040 to sustain an average “three star” aged care system; to improve to a “four star” system would require 518,000 direct care workers. The numbers exceed 600,000 direct care workers in 2050.
2040 is now closer to us than 2001. Where will those additional workers come from? OECD data shows the average age of the LTC workforce is 45 — older than the overall workforce. In Australia in 2016 it was 46. Our aged care workforce is getting younger, but isn’t young. The Deloitte modelling assumes that Australia will continue to source 30% of its aged care workforce from migration, and the remainder will be attracted by higher rates of pay. But there are problems with both assumptions.
First, Australia will be competing with every other developed country for aged care workers, because everyone else in the developed world is getting older: in OECD countries, by 2050 on average nearly 10% of the population will be over 80. Those countries will need around 13.5 million workers between now and 2040, just to maintain existing, inadequate standards of care.
That competition will be even more intense if China lifts its standard of care for the elderly. The current Chinese model is to rely heavily on home care for seniors, with only a tiny fraction — 3-4% — in aged care facilities. Between 2030 and 2050, the number of people over 80 in China is projected to increase from 41 million to 115 million. A more affluent China that wants higher standards of care for the elderly or with younger people less willing to care for their parents will require a colossal expansion of its aged care workforce — and they’re unlikely to all come from within China.
The Australian government, until the freeze in relations, was encouraging Australian aged care providers to enter China and expand its aged care industry. The consequences, if successful, will be significant for our capacity to lure the nearly one-third of workers that make up our own workforce.
Second, the overall health and social care sector will also be expanding to meet the needs of an ageing population — aged care will simply be the fastest-growing sub-sector in an expanding sector. Aged care will already need more nursing staff in coming years to meet the standards of care announced in the government’s aged care royal commission response (though most aged care groups wanted the government to go further and mandate 24/7 nursing staff presence in facilities). The sector will thus have to reverse its recent trend of replacing nurses with personal care workers and compete for nurses with the health sector, while handicapped by its traditional reluctance to pay aged care nurses the same as hospital staff.
There’s also the equity issue of luring away the best and most-qualified nursing staff from less developed countries to look after Western seniors, creating a brain drain for those countries that will have their own increasing aged care needs.
Luckily, as the OECD points out, there is clear evidence of what actually works to attract and keep aged care workers. “Evidence from the United States and France shows that wage increases in LTC are associated with greater recruitment of workers, longer tenure and lower turnover … Collective bargaining can be used to improve working conditions and wages in the sector.”
The only problem is, are governments and communities willing to pursue that solution?
Tomorrow: policymakers respond — with reviews instead of action.