Can we avert an aged care workforce crisis?

Australia will need to think laterally if it is to successfully cope with a predicted threefold increase in demand for aged care workers

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A UK social enterprise expert and a Sydney co-operative of care workers are on a mission to show that incentivised employees can help iron out some of the toughest problems in aged care and disability services.

Guy Turnbull, a recent UK Entrepreneur of the Year who is currently a Thinker in Residence at the Don Dunstan Foundation in South Australia, says a co-operative business model is one way that policy planners can dig the sector out of its morale and funding woes.

“One of the problems, here and in the UK, is the difficulty of being able to recruit and retain a quality workforce. Demand is going up for both disability and aged care services, but we have an environment of austerity and a shortage of labour,” he said.

Mr Turnbull established Care and Share Associates (CASA) in northern England in 2004 after a background in setting up co-operatives for local government. The business now provides more than 23,000 hours of care per week and has flourished by offering enhanced training and career opportunity for its member-workers.

“If you work for us, you get a share in the business and a share in the profits. It creates engaged employees, and you need engaged employees to deliver high-quality care,” he told The Medical Republic.

In Australia, he has been consulting on disability workforce responses with the South Australian government and private sector, and plans to set up a new community care service in Adelaide by linking a Sydney-based co-operative of home care staff to a network of GPs and allied health providers.

So, how does he assess the Australian context?

“Firstly, if we look at the disability space, one of the problems of consumer-directed care under the NDIS is that they are creating thousands of mini-commissioners, so nobody is taking a view on workforce strategy and planning,” he said.

“So you’ve got no way of understanding who wants what and when.”

He suggests a joint venture association of providers could be used to harvest data to identify needs and activity.

In aged care, projected workforce demands make for a daunting task ahead. Some 1.3 million Australians currently receive some form of aged care subsidised by the Australian government, the vast majority receiving services at home rather than in aged care residential facilities.

By 2050, the number needing care is projected to reach 6 million, requiring a three-fold increase in aged-care workforce demand from 336,000 to 1 million across the professions.

“I don’t know how you are going to do it. There are only 20 million or so of you,” Mr Turnbull said, emphasising the need for practical steps to make home-care work more attractive.

“One of the issues around the workforce challenge is that carer positions are casualised and devalued,” he said.

“Actually, this is an industry where you can go in with very little qualifications and very little experience, but if are prepared to work and train hard, you can progress a long way.  And by actually straddling more than one piece of the modern health and social care system, you can offer really good careers.

“That’s what we need to do. The challenge is huge.”

He says the cooperative model developed at CASA improved carers’ satisfaction and career prospects.

“What we did is, we invested in our own registered training organisation where people could learn on the job. So you could join us as a domestic doing very low-level tasks, but with the training and qualifications you could end up being delegated more tasks in the home and earning more and have much more stability in your life.

“The other thing we found in the UK, as we went into complex and end-of-life palliative care, is that with a co-operative you can spread over more of the health and care economy.  You can offer career progression.”

In coming months, Mr Turnbull plans to introduce a Sydney-based co-op of care workers to Adelaide, which will connect with GPs and allied health workers in a trial of wrap-around community-based care.

“We are going to bring it to Adelaide, but do it with a GP consortia. I think what we’ve learned in the UK is that you need to link up care, nursing and allied health professions to stop people going into the acute sector in the first place and then supporting rapid discharge from hospital.

“In the UK, we have people staying in hospital, because there wasn’t sufficient community care to discharge them to.”

The Adelaide trial will include The Co-operative Life, (TCL) an outfit established in Sydney in 2013 by care worker Robyn Kaczmarek and a handful of associates.  At the time, worker-owned co-ops were rare in Australia; TCL is believed to be the very first in this sector.

The co-op now employs 80 carers, of whom about half have joined as members, providing NDIS and aged care services to clients in their homes. It has recently expanded to the New England region of NSW by taking over a failed NDIS provider, saving 26 jobs.

“We provide the care in small self-managed teams who decide their own rosters so people can live and work locally,” Ms Kaczmarek, who serves as CEO as well as working in the field,  said.

“All the other resources – payments and invoicing – are taken over by the top company, so it becomes a very cost-effective model. The teams operate like a small business but they don’t have to worry about other overheads.”

The carers are all certified or working towards a Certificate 3 qualification, and the co-op assists them with training and practical tests. As policy, the teams identify their clients’ healthcare providers and help connect them to services.

“We ask: who is your GP, your dentist, your podiatrist? You’d be amazed at how many people don’t even have those,” she added.

“What Guy is trying to do is formalise that arrangement so that people don’t start to fall through the gaps, which is really what we see a lot of.  We see people who don’t have GP connections and they end up in hospital, which the most expensive place for them, and maybe they don’t even need to be there.”

With doors opening in Adelaide for a co-op trial including GPs, pharmacists and other allied health, Ms Kaczmarek hopes to take the model further, seeing particular need in rural and remote areas where aged care and disability services are thin.

Adelaide GP Dr Andrew Kellie is keen to explore the concept after attending a lecture by Mr Turnbull.

“This about what the market can do in a broader sense to bring business owners and individuals together who might have common interests and values in terms of providing what we consider to be value-based care,” Dr Kellie said.

“In terms of my exposure to Guy and Robyn, one of the things we’ve been trying to understand is what the potent vehicles are for collaborating together and sharing benefits while still maintaining our individual businesses.

“What we are imagining potentially is a kind of co-operative of co-operatives, if you like, where various segments of care come together. The Co-operative Life is predominantly a home care provider, we have healthcare providers, and then there are social care services with particular needs in NDIS and aged care.

“They are some of our wickedest problems in terms of providing care. What we really need are solutions where each of those parts of the care provider spectrum come to work together.”

He considers GPs would be particularly interested in a way to assist their patients beyond the confines of their clinic.

“For us to be able to have appropriate conversations across the care spectrum, with home care and social services, that’s really where the benefits lie,” he said.

Dr Kellie muses over whether the co-op model might be the way of the future for cash-strapped health and social services.

“The interesting thing about co-operatives is they seem to have bipartisan support the world over. From a left point of view, they have a social imperative and a shared citizenship. But if you look at it from the right, it’s also a way of supporting small business and entrepreneurialism,” he said.

“The really interesting question for us as a society, I think is whether there is a need for us to have more services from a care perspective delivered by organisations where profit is not a primary motive.

“That’s a fundamental question across health – whether the market can sustain the cost associated with the imperative for profitability, compared with things like co-operatives, where you can empower the employee and give them a stake in its viability.”

Ms Kaczmarek describes TCL as a “cost-recovery business” rather than a money maker.

“Aged care and disability are both cost-recovery services. Aged care has a little more flexibility, but NDIS prices are fixed. There’s only about 3% profit to run the rest of your business, so we are seeing real gaps,” she said.

“I think we are going to see market failure among large organisations that have usually been bulk-funded and can’t afford to offer the services they used to.”

In one sign that change is stirring, she has recently been fielding requests for advice and assistance about the co-op model from groups aiming to fill gaps where councils and other organisations have dropped services.

And, also in Adelaide, a formerly state-run provider of early intervention services for children with disability and developmental delay has been revamped as a mutual, held and run by allied-health and support workers. The new operation started trading as Kudos Services early this month.

Ms Kaczmarek’s set up TCL as a direct response to her unhappy experience with for-profit home-care agencies.

“I needed a job. Like many of the care workers who enter this industry through a change of circumstances such as a divorce. You want it to be a good job, so you think aged care and disability services are always in need, it’s an accessible job, I think I could do that,” she said.

“The conditions were appalling; you basically get a list saying here’s the people you will see and you just have to get in your car and go. You turn up alone and go into a house unknown; they don’t know who you are. If there was a problem – and there were problems – you would call your coordinator and no one answered the phone.”

Typically, workers were paid cash in hand, with no sick leave or holiday pay, she said.

Some recently divorced women were living out of their cars and doing 24-7 care so they’d have a place to sleep at night. Workers trying their best and doing a great job were being shouted at by unhappy families and unhappy clients.

She got the requisite qualifications and formed a business acting as a private case manager for families needing help accessing aged-care services. She navigated the aged care system and made sure services were delivered. Then she found herself needing staff.

“I just couldn’t face the idea of becoming like those horrible agencies,” she said.

Of course, the collective style of business has other rewards, reflected in TCL’s just-completed first benchmark staff survey.

“Most of them say they appreciate being a part of the conversation; they feel they have a meaningful contribution in that they are always involved in decision making,” the CEO reports.

“They have a job and they get paid fairly and on time. We have an open book, so they can see what everyone else is earning. I think the main thing is, they feel we care. That’s why people come to us and wanted to work with us.

“It’s good to feel needed and wanted, isn’t it?”

Her next ambition is to establish a training arm for care workers, which would need to be outside the existing service organisation “because we can’t afford to train our staff any more with the money that’s coming in”.

A pressing ongoing project is creating a program with the Business Council of Cooperatives and Mutuals to make the employee-owned business model more accessible and better understood.

“We have been teaching it off our own bat, as we grow it gets more difficult to do. So we need to get something more formal in place so people understand what it means to be an owner – the financials, the parameters of where we are today and where we will be in six months, and the core processes and principles of being a co-operative.”