As both of those metrics continue to move in opposite directions, sometime soon we will reach a critical imbalance, and when that tipping point arrives, the outcomes for Kiwis in aged care could be dire.

At the recent Grant Thornton Aged Care Forum, industry experts Norah Barlow, Simon Wallace, Scott Scoullar and Grant Thornton Australia’s National Head of Health and Aged Care, Darrell Price talked about the challenges facing the sector. The biggest problem stood out starkly: a severely understaffed aged care sector is no longer merely a possibility, but a clear and present danger affecting our elderly population.

Nursing pay gap undervalues aged care professionals and our elderly community

The problem is clear and easily recognisable. Internally we aren’t producing enough nurses to keep up with the demand and we haven’t been for some time. This is an international trend. But it’s not just nurses in general, it’s also nurses who want to work in the aged care sector.

At Grant Thornton’s Aged Care Forum, Norah Barlow said, “Why would a nurse want to work in the aged care industry when they could be earning $20k more at a DHB?” Barlow also emphasised that many aged care environments often have poorer working conditions, unlike DHBs which offer larger teams and support networks, “There’s a huge burden of responsibility and pressure on nurses who work in understaffed care facilities, they are often overworked and underpaid and nothing is being done to correct this disparity. If nothing else, this is a clear indication around the value we place on our elderly population.”

It’s no secret that aged care workers are in short supply. In 2018, aged care vacancies reached a record level and it was predicted we would soon be 1,000 workers short. In 2019, a survey found 83% of aged care nurses thought some basic care was delayed or missed. In 2020, before covid hit, the New Zealand Nurses Organisation chose understaffing in aged care as its focus for Caregivers Week, commenting that, “current staffing levels are inadequate, and our elderly deserve far better.” The question remains, what is being done about it?

Closed borders exacerbate a long-standing problem

With closed borders and almost no ability to employ from overseas, the number of aged care workers is falling even faster than it was before the pandemic. The pace of the problem has accelerated but the solutions have not.

Although carers have had their visas extended and our existing international nurse workforce can remain here, numbers are still low. Some international nurses report not being able to relocate their families to join them here in New Zealand; as a result, they’ve decided to return home. An additional 350 nurses have valid visas to come to New Zealand specifically for aged care, but issues with booking MIQ spots is causing serious delays. It seems no matter what providers try, the problem becomes harder to solve.

During the Aged Care Forum, Simon Wallace explained that New Zealand now has 900 nurse vacancies, “In a normal environment finding this number of qualified nurses is a challenge, finding them during a global pandemic is almost impossible because now we’re also competing for our own talent as the world looks to secure this very precious and valuable resource.” Adding a further squeeze, our neighbours across the ditch are in a similar position, and they’re looking to us for a solution. Darrell Price put it bluntly: “we will be headhunting New Zealand nurses.”

An aging population, waiting longer for formal care

This crisis of staffing also comes at a point when demand is steady and growing. While our aging population in New Zealand is increasing, we are also seeing changes in the way care is being accessed. The biggest trend is that older New Zealanders are choosing to wait longer to access formal care, which means by the time they arrive at a facility their stay will be shorter, but their need for expert care is more acute.

Barlow says it’s a human response, “Senior Kiwis are often choosing to ‘age in place’ at home, delaying their move into an aged care facility for as long as possible. The reasons are simple, it’s cheaper for the DHBs to provide at lower care levels than formal care and there are some emotional benefits around being at home; but staying at home doesn’t always provide them with everything they need and can put enormous pressure on spouses and family members. Those with challenging conditions like dementia, for example, need much closer management, which is why aged care providers sometimes offer specific memory care facilities - a level of care impossible to achieve in a home setting”.

In response to this trend, one option for those who want to ‘age in place’ is home care nurses, provided by live-in carers - a viable alternative for those who can afford it. However, they are in hot demand and short supply. While this type of care has its advantages, it’s extremely hard to regulate and assess. It is also far less efficient than having people living together and being cared for in a group. In many cases, despite a high level of care from a home nurse, the person’s needs mean they must eventually move into an aged care facility to get round-the-clock care from a specialist team.

A big challenge facing the sector is that the ‘age in place’ option will continue to grow, particularly as the nursing shortage continues to bite. The prospect of going into care becomes a bleak one when it’s clear our loved ones will not be able to receive the care they need or deserve. We all say we want to stay at home, but we just don’t want to get old and sick and frail. Sadly though, most of us will end up in care.

Closed facilities, poorer care outcomes, pressure on hospitals

If these trends continue, the likely outcome of ongoing staff shortages, combined with rising wages and no increase in Government funding is clear. Staff will leave the sector and aged care facilities will begin to close. This is already happening says Wallace, “We already know of 15 aged residential care sites that have closed entirely or closed some or all of their hospital level beds in the last few months.”

The larger, more profitable aged care businesses tend to have greater resilience in the form of property development and retirement living, but Scott Scoullar of Summerset says this is necessary to maintain levels of care, “Funding from the government is between $130 and $250 per night. Contextualise that against what I understand is close to $1,000 per day in a public hospital or the cost to stay in MIQ or a hotel room – and hotels don’t have to provide healthcare staff, medication, food or services.”

For those providers in the sector where government funding is the only revenue stream, the chances of survival are much lower. Small provincial providers are often the first places to close leaving aging Kiwis in small towns with the choice of moving away from their families to go into a retirement village, or aging in place with all the compromises that entails.

Worse still is the spectre of understaffed facilities, with overworked carers who can’t achieve the required standard of care, let alone the outstanding level of care they want to provide. When carers burn out and leave the industry, even more pressure is exerted on those who remain. Overall, it’s not a compelling recruitment message for those nurses considering a move into the aged care sector and the unfortunate reality of this is an increasing likelihood of inadequate care and preventable deaths.

“The brutal reality is that you can’t reduce staffing levels without providing lower levels of care – the burden of responsibility is massive, and it’s a self-perpetuating situation; the longer it takes for funding to be corrected in the sector, the harder it is going to be to recruit nurses. The aged care funding from Government is unsustainable” said Scoullar.

While for the majority of the population the challenges in aged care can seem remote and disconnected from our day-to-day reality, things start to bite closer to home when we ourselves need care. Inevitably as aged care facilities struggle to survive, more people requiring care will create a heavier burden on the public healthcare system. The news isn’t good for anyone. DHBs under pressure means the level of care for the wider population deteriorates, and if you’re an aging New Zealander looking for somewhere to live and receive care at the same time, long term hospitalisation is a bleak prospect.

“This is an extremely grave situation that serves to distract us from the positives we should be celebrating. The sector did an extraordinary job around covid last year – the best in the world – and they should take heart from that,” Wallace told the forum. “But the shortage of nurses is causing a ripple effect across the healthcare sector and without immediate solutions the care of older New Zealanders may be impacted”.