Systemic Implications of Immigration Changes in Australia: Ageing Cohort Analysis and Effects

Abstract

We examine immigration, population ageing and the aged care workforce, as well as making suggestions for their effects on health, aged and social care including more localised implications. While there is now a push to reopen borders, and while numbers are rising, it is as yet unclear if the ‘old order’ will resurge or if the situation has changed for the foreseeable future. We draw on data from a variety of official sources in a developmental discussion of the current and likely future effects of labour migration patterns, workforce supply and demand issues in Australia, and the lingering effects of the COVID-19 pandemic. For a variety of reasons, the data used here are emergent and the effects on current and future workforce requirements will be varied at several levels. Australia’s ageing population and associated health and social care needs are dynamic in themselves, but they are also situated within a broader international context. There is a need for ongoing monitoring and evaluation of how these factors intersect and likely future scenarios.

1. Introduction

In this chapter we explore some of the intersectional characteristics of Australia’s dynamic and changing demography, and association with its immigration and the aged care systems. This is important because the Australian population is ageing, and that process is projected to accelerate in the coming two decades. In addition, the residential aged care sector, in particular, cares for many medically unwell older people, often in their last few years of life. The workforce in this sector has long relied on recent immigrants and their connections to countries of origin (e.g. Nepal and the Philippines) to maintain essential staffing levels. The sector is challenged by low wages and limited career opportunities resulting in high staff turnover [1].

The global pandemic presented by COVID-19 has presented additional challenges to the aged care sector in Australia and elsewhere. Older people suffered much worse in a number of countries including Australia because ageist rhetorics prevailed (the co-morbidity argument for example) and slow or ineffective responses to the pandemic led to many deaths in older cohorts [2, 3]. These were often well above those experienced by other sections of the population. In some places, workers even abandoned their residents to their fates, while in others, officials discharged infected people to aged care facilities, spreading the disease to vulnerable residents and patients [4]. In Australia, some aged care workers feared for their own safety in a situation where PPE was not always available, and Federal and state government(s) often seemed to care less about older people and their care providers [5]. Certainly, older people and especially people in residential aged care facilities were (and remained) at greater risk during the pandemic.

A consequence of the last few years has been that the aged care sector is perhaps less stable than before and at a time when the need for both residential and in-community care is rising. Where this is headed and the effectiveness (or lack of it) of the current system is yet to be seen. The Royal Commission into Aged Care had already made more than 100 recommendations for change to the existing aged care system. A number of these (11) applied specifically to the workforce and associated issues and constituted the fourth pillar of the Commission’s response [1]. The challenges identified by the Royal Commission included a direct acknowledgement that demand for skilled workers in this sector can only continue to grow, while the supply side lags and working conditions are uncompetitive with other industry sectors.

“The gap between supply and demand for aged care workers has widened, even since the royal commission’s interim report in 2019. What’s more, the shortfall in workers is expected to worsen. The royal commission reported an estimated need for more than 130,000 additional, full-time equivalent workers by 2050—a 70% increase on current levels. In-principle government acceptance of a national registration scheme (recommendation 79) and a minimum Certificate III qualification (recommendation 78), both of which will be initiated through a code of conduct mechanism and national register administered by the Aged Care Quality and Safety Commission, may further exacerbate this gap in the short term.” [6]

A change of government in Australia in 2022 also shifted the prevailing policy and funding environment such that systemic instability is likely for some time to come. A key factor in all of this includes the size, composition and skill of the workforce and the capacity to maintain and develop that workforce in the coming years. The current Aged Care Act [7] is under review, it was amended in late 2022 but a new Act is proposed. Also, aged care providers are adding their perspective to current discussions around the aged care workforce, where those workers may come from and how best to attract and retain them. These are positive indicators, but this problem has a long-established history of concerns, failures and persisting employment issues [8, 9].

2. Immigration and the aged care workforce

There is a considerable immigration literature that is well beyond the scope of this chapter to summarise. However, because we are focusing more specifically on aged care in the Australian context, it is important to note that there is, even here, an established and growing research literature. The aim of this research and associated projects is to address key issues around the intersectional nature of Australian immigration patterns, workforce demand, and the experience of those workers. Care work, in particular, has a substantial and growing critical literature since, in many cases, immigration women are paid (often quite poorly) to do care work that they would more usually be providing to their own families [10]. This has become an established characteristic of the growing commodification of aged care work in particular, including the various social, physical and affective dimensions of care work [11, 12].

In the Australian context, the intersectionality of immigration and the aged care sector is comparatively recent as a focus for academic research, even though concerns about funding and delivery long preceded this [13]. The Australian Federal Department of Health and Ageing first published a National Aged Care Workforce Strategy in 2005 illustrating that the issue was gaining attention at the national policy level. This was followed by a more critical examination of the ‘crisis in aged care’ by Graeme Hugo [14], who published extensively on Australian demography and population ageing more specifically. Fine and Mitchell [15] wrote anticipating labour shortages in this sector, especially as population ageing progressed and the demand for more workers grew. They estimated a need for more than 290,000 workers in the sector by the year 2031. Since then, the availability of an aged care workforce has been a consistent and recurrent concern of government, industry and the community. The emergence of the COVID-19 pandemic made this concern even more acute, as it did internationally. Consequently, we can see that the aged care workforce is both a feature of and also reactive to current and emerging conditions–ranging from immigration policy to ageing trends and workforce policy and funding.

3. National level demographic trends

At the international level, we know that skilled migration represents a competitive environment for many of the higher income countries and so Australia has to be able to offer an attractive migration environment [16]. It seems likely that, as with the international student market (which also serviced the aged care sector to some degree) this remains to be clarified. The Brexit scenario in the United Kingdom and associated loss of many international workers may represent an opportunity for Australia but many of the higher skilled NHS workers were from mainland Europe and thus were regional relocations more than transnational migrants. They could more easily work in the United Kingdom and still travel easily back to their countries of origin. For the aged care sector, the workforce demand situation is broader in that workers at all skill levels are required to sustain current and emerging demand [17].

Other issues currently facing Australia include a growing impact from climate change and climate-related disaster events. While these are not affecting major urban areas at present, many regions and regional centres have been acutely affected by bushfires and flooding in recent years and the expectation is that such events will increase in frequency and severity [18]. These affect not only communities themselves but also emergency services, first responders, and acute and social care providers but also aged care facilities which often need to evacuate flood and fire prone areas. The capacity to respond to such events effectively relies to a marked degree on the preparedness, skills and motivation of the workforce and its management team(s). The unique geography of Australia makes for a key consideration in meeting the needs of an ageing population and in successfully recruiting and retaining health and aged care workers for these settings [19].

4. Data and methods

In this developmental piece, we draw on data form official sources only. These are, usually, government information sources used because they are accepted by academic and industry users. One of the more obvious limitations with government data sets can be the lag time in the collection, analysis and release of such data. In addition, different data providers may have different approaches to the level of detail in the data they collect as well as in what they release. Likewise, analytical and visualisation methods may vary, although this scenario is improving in the Australian context as public sector providers invest time and effort in the application of data visualisation software to enhance access to their data and its utility for different kinds of audiences. On the spatial side of this equation, there is still some way to go as issues of privacy, and perhaps a lack of familiarity (outside of infirmed users), slow developments here.

Consequently, the data that informs this discussion come from a more than one source and the ultimate storey they present requires interpretation. A second consideration is that the timing of such data releases and the complexities arising from the impact of COVID-19 at the international, national and sub-national levels are far from settled. These types of factors contribute to the developmental nature of our discussion but, also, add to its interest since a variety of audiences have an interest in how the pandemic and its lingering effects intersect with workforce issues and, ultimately, our capacity to service and care for various groups in an ageing population.

5. Contemporary population ageing in Australia

Australia’s population is ageing and the rate at which it is doing is rising. At the 2021 Census, the total population was just over 25 million people [20]. Of this total, almost 4.4 million were aged 65 years and over or 17.2%. This represented a growth in the older population from the 2016 Census level of 15.8%. While this is not rapid growth across the intercensal period, nonetheless all data and associated projections indicate that population ageing is progressing and will grow much more rapidly from the mid 2020’s onwards [21].

This trend has a variety of implications including many more older people living in the community, also more people transitioning to aged care facilities as their health declines, as well as more people dying in any given year (the pandemic appears to be driving some of this shift). The pattern of growth in residential aged care was rapid for some years but that appears to be levelling out to some degree as access to services in the community improves and/or people choose not to transition to residential care unless they are genuinely medically unwell. In the past residential aged care included a higher component of ‘nursing home’ accommodation and options that afforded home-like living and support. However, this pattern has shifted to include a growing emphasis on home-based supports that can slow the transition to residential aged care, a system which is expensive for government since much of it is privatised due to previous policy commitments and ideological positions.

The point we make here is that this intimate connection between population dynamics, such as population ageing, and the epidemiology of ageing have multiple implications for the workforce, in addition to those they have older people in both community and residential aged care environments. One strategy that needs to be considered mush more seriously than it has in the past, we propose, is both prevention and management of such conditions. If the aim is to prevent harms and suffering to older people, then we need to develop much more of an ‘upstream’ focus than has been the case previously.

The emergence of the COVID-19 pandemic has also had a major impact on older people, which is the focus of a growing literature of its own. Many examples exist of how older people experienced a disproportionate degree of illness and death from COVID-19, often glossed as largely a consequence of ‘pre-existing conditions’ [22]. In addition to its immediate effects, it has also raised the spectre of long-COVID-19 sufferers for whom dementia and other conditions will be an important factor [23].

The Centre for Excellence in Population Ageing Research (CEPAR) has recently published updated projections for future patterns of ageing across Australia [24]. At the national level, they estimate that over the two decades 2021–2041 the older population will increase substantially in the 65–84 (grouped) cohorts (42.4%) but even more dramatically in the 85–99 (139.3%) and 100+ grouped cohorts (200.4%). The 85+ cohorts represent perhaps the greatest challenge to existing models of care and associated resource distributions in health and social care more generally. This is in part due to the rising proportion of older women in this grouping, often living with multiple health conditions and various forms of disability [25].

This analysis affirms the need for not only change in aged care policy but corresponding shifts in the aged care workforce, how it is managed and the skills that will be needed. While we have limited space to go into detail here, the geography of the ageing population in Australia is also likely to present a challenge in that it is already difficult to supply many regional, rural and remote areas with the workforce they need. This situation is only likely to become more acute unless incentives can be designed to bridge the gap between major metropolitan areas and these others. This brings us back to the need for greater and more effective integration of the health, aged and disability care sectors. Current policy-based silo approaches are already inadequate to address existing problems and it seems very clear they will be even less adequate as the trends discussed here progress and intensify.

A key feature of Australia’s population ageing trend is that growth in the older and oldest old cohorts is rising faster that those under 75 years of age. The chart below from Wilson and Temple [24] also illustrates this clearly, as growth in the 85+ cohorts is clearly steepening through to 2041 in two phases, firstly 2021–2031 and then again from 2031 to 2041. This is important because it means that factors such as frailty, support needs and health interventions are already likely to characterise those growing numbers of much older people and the demands their care is likely to place on service providers can only grow (Table 1).

Age group	2021	2031	2041	No.	%
0–14	4,750,600	4,895,200	5,323,900	573,300	12.1
15–24	3,103,000	3,714,200	3,864,400	761,400	24.5
25–64	13,520,700	14,561,300	16,190,100	2,669,400	19.7
65–84	3,779,500	4,799,400	5,381,300	1,601,800	42.4
85–99	529,000	800,300	1,265,700	736,700	139.3
100+	5300	10,500	15,900	10,600	200.4
Total	25,688,100	28,780,900	32,041,300	6,353,200

Table 1.

Projected population growth by broad age group, Australia, selected years population change 2021–2041.

Source: Wilson and Temple [24].

In addition, we can say with some confidence that, although the data is developmental, it is very likely that long COVID-19 will make a broad contribution to the intersection of these health and ageing issues and their associated systemic demand. This includes a rise in the average number of deaths in any year, growth in the chronic disease states associated with COVID-19 (including heart and lung problems) and the dementias as small vessel disease and related neurological factors play out [26]. The re-emergence of major infectious disease is a major complicating factor for many of the higher income countries since it complicates accepted trends and compounds the need for more health resources, including skilled workers being available at the point of care.

This complex mix of demographic, epidemiological and systemic factors has implications for the kind of workforce needed in Australia and, consequently, the nature of its immigration programs going into the future. It has implications for educational and skill levels and, consequentially, for pay rates and working conditions. Internal migration must also be considered since there has been an uptick in people relocating to coastal centres, many of which are already ageing (e.g. Port Macquarie and Tweed Heads in New South Wales). These issues are already highly topical in Australia as the Royal Commission into Aged Care [1] illustrated very clearly and subsequent investigations and research largely support. One thing that is very apparent is that the current competition for labour that has emerged in the not-quite post-COVID-19 environment will have important flow-on effects for the aged care sector.

6. Australian immigration patterns

The post-war period brought many immigrants from Europe including countries such as the UK, the Netherlands, Italy, Greece and others. These cohorts have now aged, with limited continuing immigrating from those countries for various reasons, including the rebuilding of European economies in the 1950s and 1960s. Now, as the chart below illustrates, the pattern has shifted yet again. Over the decade from the 2011 to 2021 censuses, England has maintained its position as the major source country but India and China, for example, have grown significantly and quite rapidly. By way of contrast the reader can see that Italy is still a source country but at a much-reduced level than in the post-war period and the trend is downwards over the decade.

These data suggest that the diversity of immigrant cohorts is high but that their correspondence with the previous immigrant groups that are now aged is quite low. In other words, there is a continuing disconnect, specialist services aside, between some ageing cohorts and the workforce available to meet their care needs. To some extent this is inevitable because both migration and aged care are enmeshed in a set of international trends and variables that they cannot control. A consequence of this is that factors such as the cultural diversity of workers and aged care recipients needs to be integral to models of care if that care is to be provided to the best possible standard (Figure 1).

Figure 1.

Overseas-born population by country of birth. Source: ABS, 2021 Census (2021 data are estimates) [20].

The ABS also notes that the major countries of origin vary for each state and territory in Australia. So, in NSW the state with the largest population, Nepal is the largest contributor. For the states of Victoria, Queensland and South Australia, India is the main source country. In Western Australia, that country is the Philippines. Then, Samoa was the highest contributor for Tasmania, Afghanistan were the highest contributors for the Northern Territory and China for the Australian Capital Territory (ACT) respectively. This varied patterning of migration and country of origin by state and territory leads us to look more closely at the migration program itself and its key sub-programs.

7. Australian immigration by migration program

The data in this section is from a 2023 data release by the Australian Department of Home Affairs [26]. The Table 2 shows the particular dynamic between skilled migration and family migration which shifted during the COVID-19 pandemic. During 2020–2021 in particular we can see that the ratio of skilled migrants to family altered dramatically from a rough split of two-thirds to one-third in preceding years to an almost 50:50 split. In the following year, 2021–2022, this began to shift again but clearly there was a lingering COVID-19 effect. In addition, the overall immigration figure dropped significantly from a total usually much closer to 200,000 people per year to between 140,000 and 160,000 across the 2019–2022 periods. This trend will be interesting to monitor as internal Australian factors develop, such as a new Aged Care Act and reforms to policies, funding and workforce issues. What may also need to be considered is how external factors contribute to the emergent pattern as the health and social care sectors. In the next section we explore available data on some of these issues in more detail.

Outcome	Stream
Year	Skill	Family	Child	Special eligibility	Total	% Skill	% Family
2011–2012	125,755	58,604	0	639	184,998	68	31.7
2012–2013	128,973	60,185	0	842	190,000	67.9	31.7
2013–2014	128,550	31,112	0	338	190,000	67.7	32.2
2014–2015	127,774	61,085	0	238	189,097	67.6	32.3
2015–2016	128,550	57,400	3512	308	189,770	69	30.8
2016–2017	123,567	56,220	3400	421	183,608	68.6	31.2
2017–2018	111,099	47,732	3350	236	162,417	69.8	30
2018–2019	109,713	47,247	3248	115	160,323	69.8	30.1
2019–2020	95,843	41,961	2481	81	140,366	69.5	30.4
2020–2021	79,620	77,372	3006	54	160,052	50.7	49.3
2021–2022	89,063	51,288	3006	199	143,556	63.4	36.5

Table 2.

Immigration program outcomes 2011-2022.

Source: Department of Home Affairs, Australian Government [26].

8. Australian arrivals by occupational category over time

The table below shows that the percentage of arrivals in the health and social assistance categories is and remains high compared to many other occupational groupings. However, we can see that as at the end of 2022, the year this data was collated, this percentage had fallen from previous periods.

This illustrates the variability in workforce composition over time in response to both internal and external factors (Table 3).

	Total (% of industries)
Industry	Arrived less than 5 years ago	Arrived 5 to 10 years ago	Arrived more than 10 plus years ago
Accommodation and food services	13.74	8.16	6.83
Administrative and support services	15.36	10.83	9.73
Agriculture, forestry and fishing	1.24	0.9	0.66
Arts and recreation services	1.34	1.29	1.47
Construction	4.1	5.56	5.25
Education and training	5.29	5.72	6.87
Electricity, gas, water and waste services	0.38	0.57	0.7
Financial and insurance services	3.01	4.15	4.84
Health care and social assistance	12.23	16.19	15.3
Information media and telecommunications	1.43	1.58	1.6
Manufacturing	4.35	5.14	5.4
Mining	0.43	0.97	0.98
Other services	3.31	3.59	3.39
Professional, scientific and technical services	11.22	10.79	9.88
Public administration and safety	1.79	3.06	4.56
Rental, hiring and real estate services	1.46	1.64	1.65
Retail trade	8.49	7.47	7.98
Transport, postal and warehousing	4.92	4.84	4.93
Wholesale trade	3.39	3.78	3.88
Total	100	100	100

Table 3.

Immigration by industry sector and time of arrival.

Source: Australian Bureau of Statistics [20].

In addition, the gendered nature of this data is also useful in that the health social assistance category is a significant component of the overall immigration pattern. For those who arrived less than 5 years ago, 18.94% of total female arrivals were in this category compared to 6.19% of total male arrivals. The same basic pattern applies also to those who arrived 5–10 years ago (24.77% female versus 8.2% male) and those who arrived more than a decade ago (23.2% female versus 7.38% male). Thus, this gender skew is persistent over time and a significant feature of the health and social care sectors (Figure 2).

Figure 2.

Immigration by gender in the health and social assistance migration category. Source: Australian Bureau of Statistics [20].

9. Growing need for care and support

A number of factors can be identified in looking to the health and social care needs of older people in this shifting Australian context. One is that the workforce needs to grow and diversify in terms of skills, qualifications, and experiences. Many nurses, for example, resigned during and after COVID-19 struck and it remains unclear if they will return to the workforce. The wider health workforce itself is ageing and so skilled workers were already a concern. This means that many of the older current health and social care workforce may yet become clients of the system in which they currently work. There is therefore a multi-level demographic patterning to the issue of how aged care will be resourced and by whom.

The past immigration pattern in Australia means that many older European cohorts may revert to their first language without a corresponding language skills base in the care providing workforce. So, for example, while a very large Italian (and Italian dialect) speaking cohort is ageing rapidly in Australia, recent arrivals from Italy are very low by comparison (see above). Countries of origin for the current and emerging aged care workforce do not correspond to the existing aged care patterning of the population and thus other cross-cultural skills may be needed to provide effective care. Even in large communities such as those from Mainland China, who are more recent arrivals, the risk exists that some individuals may be socially isolated by the lack of resources available in their first or primary language or dialect, with corresponding implications for communication and support in key areas of health, nutrition, self-care and end-of-life care where factors like consent are or should be central to service provision.

“At 30 June 2021 (or during the 2020–21 financial year for home support), across all mainstream aged care services, 33% of people were born overseas, of whom 66% were born in non-English-speaking countries. Significant proportions of people using aged care services had preferred languages other than English—9% in permanent residential aged care, 17% in home care and 10% in home support.” AIHW [27].

The AIHW [27] data indicates that one-third of all current aged care service recipients are overseas born and two-thirds of those are from non-English speaking countries. What also needs to be considered is the extent to which this group utilises formal aged care services in the first instance, given that language and cultural issues may be barriers to services that are not ethno-specific or able to meet care needs outside of an English-language mainstream model and its associated assumptions including food, religion and cultural practises. An associated concern is where and how Indigenous Australians are able to access safe and culturally appropriate care (especially if not living on country) and the role of the aged care workforce in facilitating that care [28]. Aboriginal people in aged care tend to be younger than non-Aboriginal residents and while the knowledge base on Aboriginal ageing is growing, it lags behind mainstream research.

One area that has received focused research over the past decade or so is how the dementias affect older Indigenous Australians including how to assess dementia and associated cognitive impairments and neurodegenerative problems [29]. As noted earlier, population diversity and epidemiological diversity are connected and the skills and knowledge required to address them effectively require support and development in training and educational programs for aged care staff, whether domestic or via immigration program(s).

10. The Australian aged care workforce

Pivotal to any and all of these issues is the nature, skill and capacity of the aged care workforce. In this context, we suggest, that workforce is not restricted to the residential care and community aged care sectors. Rather, it needs to be seen as a more integrated whole that includes any preventive work (e.g. social prescribing and community engagement) through primary care provided by GP’s, nurses, pharmacies and allied health professionals on through ambulance and acute care services and then onwards to the aged care and disability care sectors. For the most part residential aged care is often, although not always (e.g. respite care) the tail end of a long health and illness trajectory. In our assessment, current fragment approaches are residual aspects of the system as it was rather than a system that needs to emerge.

While the majority of the aged care workforce remains locally born, the trend for immigrants to work as personal care workers, nursing and associated staff in the aged care sector has been growing for some time [30, 31]. Even with the temporary interruptions that COVID-19 produced in the existing immigration program(s), and its impact on the aged care sector itself, this dynamic is continuing. We can expect the analysis of the 2021 Census data to support the growing diversity of the aged care workforce to continue into the foreseeable future, and especially so as population ageing progresses and the demand for various forms of care and support grow. Under-funding remains a central feature of this problem [32, 33].

This situation will almost certainly be extended by imminent changes in government legislation, funding, policy and regulatory arrangements, such as requiring aged care facilities to have comprehensive registered nursing staff coverage. A factor driving some of this is the time it takes to produce skilled and experienced workers and develop them for emerging scenarios. In this context, immigration will remain central to the capability of the aged care system to meet current and emerging need.

11. Conclusion

In this chapter we have attempted to draw together some of the key demographic features of the Australian aged care environment through the lens of the aged care ‘system,’ its associated workforce concerns and the role of immigration in responding to current and future needs. We have done this in a ‘post-COVID-19’ setting although that is far from the reality of aged care and the larger issue of infectious disease re-emerging in high income countries cannot be ignored. The approach we suggest to resolving some of these issues is that national-level policies are likely to remain inadequate for managing local and regional level patterns of ageing and migration. More nuance is required if, for example, areas with well above average numbers of people aged in their 80s and above are to successfully respond to current and future health and social care needs. COVID-19 and especially long-COVID effects are likely to compound this situation for some time to come because the pandemic has had an acute phase, but we can expect a complicated post-acute phase to persist for some years to come.

To build and maintain a skilled workforce, immigration and internal migration factors will need to be managed more effectively and with a closer focus on the complexities experienced at and below the state/territory level. Current moves by the Australian Federal government to improve integration across the health, aged and social care sectors confirms the validity of this analysis and may see further initiatives in this space in coming months. This chapter comes at a time of considerable change and complexity in the Australian aged care environment and, seen through the lens of immigration and migration more broadly, we can expect these challenges to persist for the foreseeable future.

Conflict of interest

The authors declare no conflict of interest.