To Ratio Or Not To Ratio: That Is The Question

4 June 2018

The debate about ratios in aged care homes has become a stuck record. Those opposed to ratios play a couple of old favourites: the 2011 Productivity Commission Report Caring for Older Australians and Abba’s “Money Money Money”. Those in favour of ratios sing along to a protest song: “Ratios for aged care. Make them law NOW”.

To help move to the next track, politicians, the private and not-for-profit sector, families, community members and older people themselves need to work together. Working collaboratively will ensure that Australians sing from the same songbook.

To this end, I recently asked politicians, CEOs of peak bodies that represent aged care homes, unions and aged care advocates to tell me whether they support/oppose minimum ratios of registered nurses in aged care homes and why they take this position.

This led to an Opinion Piece in ABC online. In this Opinion Piece, I contest claims made by those who are opposed to mandating a minimum ratio of registered nurses in an aged care home. This opinion piece explains why I support mandating a registered nurse on site (not merely “on roster” in every aged care home 24 hours a day.

I have been a stuck record for mandating a registered nurse on site in every aged care home 24 hours a day. I first argued this in The Conversation in 2016 – and have been arguing the same point ever since.

The claim that ratios are a blunt instrument has been repeated ad nauseam since 2011. I question why we use a blunt instrument in hospitals and childcare centres, but not aged care homes. Is the government’s failure to legislate ratios based on ageism?

I demonstrate why leaving the decision whether to have a registered nurse on duty at the discretion of the manager/provider is a recipe for low standards of care, including poor palliative care. Managers who are under pressure to meet their profit targets do so by employing cheaper and less-skilled personal care attendants, rather than registered nurses.

I do, however, agree that mandating staff ratios will increase operating costs for many aged care homes that are currently understaffed. However, after reports of large profits, I do not buy claims that many aged care homes are struggling financially. The latest government inquiry Financial and tax practices of for-profit aged care providers will hopefully ‘follow the money’.

The best way for people to make up their own minds about ratios is to provide a verbatim account of the polarised positions on mandating minimum registered nurse-to-resident ratios in aged care homes. Given politicians and CEOs have access to platforms that allow their voices to be heard loud and clear, the article begins with Julie Davey, a member of stroke foundation consumer council and ends with Ken Wyatt, Minister for Aged Care.

Let’s hope the next track in the songbook is John Lennon’s Imagine.

Julie Davey, a member of Stroke Foundation Consumer Council

As a consumer and young stroke survivor, I am acutely interested in the issue of minimum RN ratios in Aged Care Homes. Given the complexity of health issues experienced by many residents, who might include younger people with neurological conditions, registered nurse ratios should be mandated. Registered nurses are able to recognise, document, communicate and assist with treatment of minor changes in a resident’s health without them having to go to hospital. Always having appropriate level of nursing staff is a way to maintain care standards, despite fluctuating availability of PCA staff. Registered nurses induct new staff to maintain care standards and educate PCA’s on the importance of consistent medication and mobilisation plans. Registered nurses can work with other Primary Care professionals (including GPs) outside the facility to avoid hospitalisation and maintain residents’ health. As staffing is often cost driven, I believe minimum RN ratios would need to be mandated to occur.

Aged care advocates

Lauren Todorovic, CarePage

Based on data, research and insights shared from families and residents – consistent themes in the feedback, tell us that ‘staff are doing the best with the resources and time they have available’. Our tools assess a number of indicators for experience and across the board one of our lowest rating criteria is “Staff presence”. This is a measure of ‘the resident or health professionals experience of staff availability and presence’. Essentially, ‘Staff presence’ encompasses if residents are feeling rushed when staff are attending to their care, if their calls for assistance are answered within a timely manner. So clearly this is a critical and sensitive issue.

Addressing this however is not necessarily simple as the industry is digesting the start of a revolution in customer experience and consumer directed care.

Whilst, (1) there needs to be more clearer guidelines on what is deemed to be a ‘safe’ resident to staff ratio, at present it’s left up to the interpretation of individual operators which is not then consistent across the board and therefore difficult to regulate. The work the ANMF have National Aged Care Staffing and Skills Mix Project provides a leaver to start to undertake data driven investigations into what works or doesn’t.

However, ultimately, this will an ongoing debate between operators, heath care professional peaks, government, families and residents as a ratio will ultimately translate into a compliance tool. The debate will shift with the implementation of data driven decision making facilitated from customer experience tools like ours, as well as sensors, IOT devices, improved facility design that mean health care workers can be more efficient, make better use of their time and ultimately better serve the resident. Staff ratios will still be an important consideration with the coming age of digitisation and better utilisation, as a compliance tool to ensure the laggards and non performers keep up, or don’t under invest in their staff. Care at the end of the day will always be a people business.

The most advanced operators on the path to improving the working environment for health professionals delivering the care are those that focus on the resident experiences. We are observing operators improving their residents experience by tracking data, listening more to consumer feedback and installing IOT or other technology innovations that stimulate evidence and data driven insights. Leadership that utilise granular data through their organisations are better positioned to move more quickly to address resourcing.

What does this have to do with ‘staff ratios’? Ratios are a compliance tool and there be creating change the only way it’s going to be materially improved if not solved is through digitisation, technology and empowering all stakeholders to be more efficient and make better data driven decisions to improve utilisation of resources (reduced stress from all people involved with technology and innovation). This debate is a critical one, but also needs to factor in the need for consumer feedback, customer experience which can only be monitored through data tracking.

What is going to start to shift this debate is the increasing awareness of digitisation for the benefit of the ultimate consumers (the residents and their families). But also new frontier technology and use of Internet of Things (IOT) devices.

Staff Ratios may help address minimum standards (and may well ultimately be a necessity to ensure compliance), but really operators, with the support of government, need to invest in innovation, improving facilities, digitising, installing sensors, engaging with predictive tools to increase efficiency and prioritise the consumer and their customer experience strategy. Only then will resource utilisation and nurse, carer and health professional well-being be optimised. If operators don’t adapt, they will be left behind.

Eliza Littleton, Senior Policy Officer, CPSA

CPSA was gobsmacked when the NSW Government made the decision that residential aged care facilities didn’t need to have a registered nurse on duty 24 hours a day, 7 days a week.  92% of resident in nursing homes need high quality care around the clock and much of this care can only be delivered by a registered nurse…Registered Nurses are senior, university trained professionals and are needed in nursing homes to administer medications, especially pain relief, provide palliative care, change catheters and ensure that changes in residents’ conditions are picked up. Without a registered nurse on duty, nursing homes frequently have no choice but to transfer residents to already overwhelmed hospital emergency departments for treatment…The only benefit of removing the 24/7 registered nurse requirement is increased profits for nursing homes, but it comes at a high cost to elderly residents and their families.

Carol Williams, Elder Care Watch

Elder Care Watch supports mandatory minimum ratios by public regulation and my reason is current ratios are ratios decided entirely by managers and the cumulative evidence of poor health care suggests far too many of them cannot be trusted with this power.

Lynda Saltarelli, Aged Care Crisis

Unlike Australia, the US government openly acknowledge that staffing levels and skills are the most critical determinants of care (Centers for Medicare and Medicaid Services, Staffing Data). They also recognise the significance of employee turnover and tenure as a “vital component of quality care for nursing home residents”. They set out recommended minimum staffing levels that are required for safe care if residents are not to be harmed – based on careful research and expert opinion.  It has made staffing and care data available for nearly 20 years.

The benchmarks our nursing homes use in determining staffing requirements are based on commercial considerations and not research.  They are developed by financial advisers who support providers and lobby government on their behalf.  They are set at artificial levels that make our very poor staffing look legitimate, providing an hours less nursing care and half the amount of care from trained nurses.

The 1997 Aged Care Act imposed an open market and a deeply flawed regulatory system on this vulnerable sector. The competitive pressure for profit has seen the uncontrolled erosion of staff numbers and skills to levels well below international standards.  Government and industry are no longer able to paper over the steady increase in the number of damning failures in care.  This policy has failed.  We need to rethink the way aged care is provided and regulated in Australia.

The last time the industry was flooded with money was in 2014.  Hardly any of that went into staffing.  Before we waste more money we need to fix the system so that we have some say in where the money goes and can check it gets there.

Words used to describe staffing such as ‘adequate’, ‘flexible’ or ‘blunt instrument’ have little relevance or meaning when the information needed to make the most important choice – who is going to care for you and help you to die without suffering is not available.

Until we have accurate data about staffing requirements, we challenge government and industry to publish online direct care staffing rosters for each home so that customers can make informed choices and advise others.


Eleanor Morgan, Aged Care Reform

Aged Care Reform support legislated minimum staff ratios and skill mix in aged care. Our recent petition gained over 2200 signatures in support of this and other reform suggestions. The myriad of concerns people have raised with us since we started our campaign can nearly all be addressed by increasing the number of staff, and moving the balance of skills back towards a greater proportion of clinical staff caring for our elderly Australians, especially in residential care facilities.
The ageing population is expanding quickly, and there are more people with wide ranging, complex health care needs entering the aged care system at all levels. There is a need for a multi-disciplinary approach to care planning in aged care, and this can only be achieved if a range of appropriately skilled health professionals are involved at all levels of care.
Currently there is no legislated requirement for either staff ratios or skill mix of any combination, and this is putting consumers and staff at grave risk. It is the responsibility of government to address this urgently via amendments to the Aged Care Act 1997 as has been repeatedly raised by multiple reports, submissions and inquiries that have been produced in at least the last decade.

Sarah Russell, Aged Care Matters

It is incorrect to say there is no empirical evidence to support mandating a minimum ratio of registered nurses in an aged care home. Staffing studies undertaken in United States, Canada, United Kingdom, Germany, Norway and Sweden show the ratio of registered nurses-to-residents has a positive impact on the standards of care in an aged care home. However, this rigorous research has been undertaken overseas, not in Australia.

Nurses’ unions

Brett Holmes, NSW Nurses and Midwives’ Association

The NSW Nurses and Midwives’ Association supports mandated nurse-to-patient ratios in aged care. Hard-pressed nurses do the best they can in impossible circumstances, but they are run off their feet and can’t provide the care they want to. Currently, residents are receiving around 2 hours and 50 minutes of care per day from nurses and carers, which is nowhere enough time to shower, toilet, medicate, dress, feed, roll over, move, let alone talk to an aged care resident. There is an urgent need for a staffing methodology that considers both staffing levels and skills mix for residential aged care across the country, which is why aged care ratios must be made law.

The staffing and skill mix report is evidence-based research carried out by the ANMF (with Flinders Uni and Uni of SA), supporting the need for ratios in aged care – this is where the 2 hours and 50 minutes figure comes from that I have referenced above:

The ANMF’s media releases in support of ratios in aged care are available online if you’d like to take something from those for their position on the matter – there are quite a few going back to 2016 in support of ratios in aged care. Otherwise I can put you in touch with their media advisor. He’d be able to get a statement from the ANMF for you today. What would be best for you? Here’s a link to their latest media releases:

The national ANMF ad campaign (running on TV, radio, social media and print) can be viewed on YouTube here:

Beth Mohle, Queensland Nurses and Midwives’ Union

Many aged care facilities are currently dangerously understaffed and vulnerable, elderly Australians are suffering as a result.  Overstretched and dedicated nurses and other staff in aged care struggle to do the best they care in very difficult circumstances.  This situation is not of their making – the system as it stands is failing elderly Australians, their families as well as staff in aged care. Unlike in child  care, the is currently no minimum staffing requirement under law, and there is also no requirement to provide the necessary skills to meet the increasing complex health care needs of residents.  There isn’t even the most basic requirement for a single Registered Nurse to be on site at every aged care facility at all times.

We have the evidence about the staffing numbers and skill mix required, what is missing is the commitment to act. In the meantime, elder abuse is occurring by neglect and we will not stand by and see this happen.  That is why we are campaigning to make ratios in aged care law now.  Please join us in sending a message to our federal politicians that our elderly, vulnerable Australians deserve better.  Stand up with us for ratios in aged care.”

Annie Butler, A/Federal Secretary,
Australian Nursing and Midwifery Federation

The ANMF strongly supports minimum registered nurse, enrolled nurse and care worker ratios in nursing homes/residential aged care facilities.

The current situation in aged care is that fewer and fewer qualified nurses are being employed to care for an increasing number of vulnerable residents with increasingly complex medical and health care needs. In a sector which has been systematically decimated with regard to staffing for more than a decade, staffing levels have now reached a critical low. Current staffing levels and skills mix profiles are too depleted to safely and effectively meet the care needs of residents, with evidence demonstrating unacceptably high levels of missed care.

The ANMF is therefore calling for the government to legislate minimum staffing ratios and skills mix in aged care as a matter of urgency. This reform must occur in tandem with legislative reform that enforces transparent reporting and public accountability of governments subsidies, ensuring that taxpayer funding is directly tied to guaranteeing the provision of safe and effective care for every resident.

Peak bodies that represent providers

Sean Rooney, CEO, LASA

Quality and high standards in aged care are not negotiable and are intrinsically linked to our industry’s workforce.

However, the provision of appropriate levels of care for older Australians in residential care facilities is not as simple as the number of staff on duty or arbitrary staffing ratios. The needs of people in residential aged care are highly variable and, within a stringent quality control system, a flexible staffing mix can deliver the best quality of care targeted at individual care needs.

In 2011, The Productivity Commission reported that “while there are superficial attractions to mandatory staffing ratios an across-the-board staffing ratio is a fairly blunt instrument for ensuring quality care because of the heterogeneous and ever-changing care needs of aged care recipients. In the Productivity Commission’s view, it is unlikely to be an efficient way to improve the quality of care. Because the basis for deciding in staffing levels and skills mix should be the care needs of the residents, it is important that these can be adjusted as the profile of care recipients changes. Imposing mandated staffing ratios could also eliminate incentives for providers to invest in innovative models of care or adopt new technologies that could assist care recipients.

Flexibility to adjust the staffing mix as the profile of residents changes is clearly a very important consideration, as is the adaptability to move to new models of care driven by innovation and technology.

Australia is facing a ‘new normal’ as the ‘baby boomers’ generation ages and it requires a shift in the way we think about the aged care workforce.

Our industry has welcomed the opportunity to work with the Federal Government’s Aged Care Workforce Taskforce, Chaired by Professor John Pollaers, which is responsible for developing a wide-ranging workforce strategy focused on ensuring safe, quality aged care for older Australians. This taskforce will report to the Government on 30 June.

Our aged care workforce of the future needs to be responsive to the changing needs and preferences of older Australians. It also needs to be adaptive to the ongoing consumer-centred reforms being rolled out by Government and provide the appropriate quality of care.

Moving forward it is also vital that the Federal Government supports high quality age services delivered by appropriately trained and qualified staff by delivering a stable and equitable funding base.

Darren Mathewson, Acting CEO of ACSA

The aged services industry is in favour of sustainable staffing that meet the care, support and lifestyle needs and choices of our residents which shift and change over time. Arguments in favour of fixed staffing numbers need to account for the fact that residential aged care is not funded to provide hospital-level care, and are homes for a mix of residents with diverse needs and choices that exist in urban, regional, rural and remote locations with differing workforce challenges. Providers operate with a budget of around $230 a day for each resident compared with $1,900 per day in acute settings.

In arguing for more staff, it must also be acknowledged that such a move would require significant additional funding from the Government and/or from residents. There also needs to be a preparedness to provide in-reach health and medical services into residential care at a higher level, ensuring equitable access for our residents and a real value add by this critical external workforce.


Senator Derryn Hinch

I moved a notice of motion last year in the Senate calling for a ratio of registered nurses. I received no support from the government, ALP, or the Greens. I also backed nurses at a recent rally in Bill Shorten’s electorate.

When I was in radio and TV, for decades my mantra about aged care was: “ The only difference between politicians and old people was that old people got there first”.  Never dreaming I would now be a  politician and old. I raised the issue with Health Department at Estimates. The current ratios, or non-ratios, are not acceptable.

Senator Rachel Siewert, Australian Greens spokesperson on ageing.

The Australian Greens acknowledge that the ratio of nursing and caring staff to residents in a lot of facilities is too low and that this needs to be addressed.  We believe that this and other workforce issues need to be urgently addressed. We urge the Government to implement the recommendations in the Senate inquiry into the Future of Australia’s aged care sector workforce. At the very least there needs to be a registered nurse present in all aged care facilities at all times (24/7).

We need an increase in our aged care workforce, we need better wages and training. We also need to make sure we have a workforce on duty that provides top quality care to residents.

Julie Collins, Shadow Minister for Ageing

Labor acknowledges that the delivery of quality care in residential care facilities for older Australians is an issue of great concern to nurses, aged care workers and the community.

Labor believes that the Government must work with unions and aged care providers to develop a strategy to meet growing demand, while ensuring decent conditions and career progression for workers and a high level of care for consumers.

This strategy must consider issues such as the proposal for 24-hour registered nurse coverage and the skill mix which enables enrolled nurses, assistant nurses and personal care workers to provide high quality care, while acknowledging the sector needs to be sustainable.”

Ken Wyatt, Minister for Aged Care

“I do not support mandated nurse to resident ratios. Flexibility, in conjunction with strict, legislated care standards is the key. While some individuals will need more specialist care, everyone in residential aged care should be supported to be as independent and healthy as possible.

This goes to the core of individualising and personalising the delivery of aged care services. Giving older Australians options and the capacity to make informed choices is fundamental to our aged care reforms, rather than mandating ratios around how their care should be delivered.

Ensuring Australian aged care has a strong supply and adequate provision of appropriately trained, skilled and resourced staff is a top Government priority. Demand is growing rapidly, with projections Australia will require almost one million aged care staff by 2050, up from the 360,000 currently employed.

That is why the Government announced a workforce taskforce last November (with a $2 million budget to support detailed consultation and research across the country) which is due to produce Australia’s first aged care workforce strategy by July 2018. The recommendations will be carefully considered because ensuring safe, quality aged care is paramount.

A new Industry Reference Committee (IRC) is also currently being formed to tackle critical skills and workforce issues identified by the Taskforce. This committee will include representation from aged care providers, unions and community groups.

There is no clear evidence or research that suggests implementing nurse or staff to patient ratios will actually increase the quality of care. (See Productivity Commission Report in background below)




  • The provision of adequate, skilled staffing and human resources are among the key standards legislated in the Aged Care Act to maintain high-quality aged care.
  • These standards are rigorously enforced. Since last July, the Turnbull Government has closed four aged care homes for not meeting aged care standards.
  • Several others are currently under sanction, including having to increase their staffing.

Regarding ratios: Productivity Commission, Caring for Older Australians (2011), Volume 2, p.367:

On balance, the Commission considers that, at this stage, the imposition of a simple staff ratio is a relatively blunt instrument, particularly given that the care resident profile of every facility will be ever changing. Such ratios become particularly problematic for small facilities, and a rigid application of ratios could create operational difficulties for these facilities. Further, the existing quality accreditation process (supported by the complaints handling process) provides a mechanism for encouraging providers to apply an appropriate skills mix and staffing level in the delivery of community and residential aged care services (appendix F).



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