‘When reality Bites’: Reshaping Aged Care Supports at Home

Robert Fitzgerald AM, the NSW Ageing and Disability Commissioner led a seminar about the lessons to be learnt from past social reforms to reshape aged care supports at home.

The following is a set of summarised speaking notes for a UTS ARC presentation in relation to the Support at Home Program outlined by the Commonwealth Government as part of its broader aged care reform agenda.

The views expressed below are those of the speaker and do not represent the views of any government or agency.

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Speaking notes:

Reform History in the Social Economy

Australia has a long history of reform in human services and the care economy, especially in the past 30 years. We have seen much innovation driven by market dynamics, technological advances and creative system design. We have seen a greater emphasis on the ability of consumers to exercise greater choice and control in the services and providers they choose.

Yet we have a very poor record of learning the important lessons from each reform and seem destined to repeat mistakes and failures when designing and implementing the next reform area. The desire for a one size fits all approach in each new reform area, especially in the establishment phases, has had unintended but predictable consequences.

Key reform initiatives in the human services area that give us particular insights include:

• Employment Services - replacing Commonwealth Employment Services (CES)
• Vocational Education and Training
• Early Childhood Development National Quality Framework
• National Disability Insurance Scheme

Each has at its core the development of regulated markets, with consumer choice central to their design and most often transactional approaches dominating the funding models.

Yet, too often we are overly concerned with the design of new markets and less about the ultimate impacts on the quality of life of the service recipients or community, especially the most vulnerable. Often the specific or different needs of certain client cohorts is ignored in the design and implementation. Rarely are differentiated funding approaches allowed for, nor is the need for different models of service provision acknowledged to meet different needs or circumstances. Too often system owners or governors are far too slow to respond to emerging evidence of the need to moderate reforms.

Employment Services reforms were dominated by the design of a new regulated market and the never-ending round of contracts based on various and ever-changing assessment criteria. Whilst the old CES approach needed a radical overhaul, it is highly questionable that the extraordinary churn in service providers, the high administrative costs incurred by both providers and government and the misuse of ‘commercial in confidence’ to prohibit information sharing and collaborative best practices, has delivered the results for unemployed people promised at the time of the reforms.

Importantly, we underestimate the levels of market disruption and the unnecessary loss of experienced and competent operators with impacts on service reliability, continuity and quality. We underestimate the increasing costs of regulatory oversight as the number of market entrants expands. And we seem ill-equipped where the number of new market entrants swamps the regulatory safeguarding systems.

We fail to grasp the fact that in the rapid expansion of new market entrants, whilst a large proportion will be competent, nevertheless a small proportion will be incompetent and a smaller number will be exploitative and dishonest- and we fail to act quickly enough to rectify such problems.

The rapid marketisation of the Vocational Educational and Training (VET) sector was based on a belief that government-run VET institutions were inefficient and that only market-driven competition could rectify this defect. Competition can drive efficiencies and bring new innovative capacity to any sector. Yet, the overly rapid and poorly regulated marketisation lead to over 5,000 RTOS. As a consequence we saw:

• A spreading of, rather than a building of, capacity
• Significant disinvestment in traditional institutions
• Incompetent and fraudulent operators, albeit in the minority
• Poor outcomes for students and employers - very evident in the sectors dealing with the care for older persons and early childhood development

The development of more person-focused, individualised, needs-based approaches within the care economy have and are being embraced by policymakers and consumers. The design of better integrated assessment arrangements, based on identifiable individual needs, is welcome. And moving from rationed systems to needs-based entitlement schemes is a very much-needed step forward in critical parts of the care economy.

Yet the accompanying one size fits all approach to a marketised, fee-for-service model fails to recognise that there are aspects of each human services system that do not lend themselves to such an approach. This may include certain service types (especially social supports), thin markets, culturally specific requirements or overly complex health and/ or mental health conditions.

Such areas may best be provided by providers who are funded by grants funding or a mix of grant, activity or case mix funding. Too often reformers seem unwilling to acknowledge that whilst a marketised, fee-for-service model may work in most circumstances and is legitimately responding to demands for greater agency or choice and control by clients, it will not and should not be forced to work in all parts of each service system.

Whilst giving greater choice and control is important to giving agency to people, for some participants, reliability of service provision by quality providers may be the most important and necessary need and aspiration. Not all consumers have the same aspirations and whilst some value choice and control above all else, others value the reliability of services and many the development of trustworthy and safe relationships.

System owners and designers need to pay much greater attention to the impacts of reforms on the level and accessibility of supply, quality and appropriateness, the characteristics of providers and the overall impacts on the quality of life of consumers, not just the nature of individualised transactions. The proposition that system owners or designers should, in the so-called pursuit of neutrality, have no regard for the nature of service providers must be seriously reconsidered if we wish to maintain the integrity, sustainability and appropriateness of service provision, especially for vulnerable people.

It is imperative that, in relation to the proposed Support at Home reforms, these issues and lessons are fully considered—as was identified in the Royal Commission into Aged Care Quality and Safety.

Aged Care Reforms

Reform to Australia’s formal aged care system is long overdue. The Royal Commission has set out clearly the need for such reform and has in large part provided clear directions for reform including articulating the key rights, principles and outcomes that should be at the heart of such reforms.

Importantly the reforms must enshrine the key concepts specified by the Royal Commission:

We propose a number of objects for the new Act, including: to provide a system of care based on a universal right to high quality, safe and timely support and care; to enable people to exercise choice and control; to ensure equity of access; and to provide for regular and independent review of the system.

The call for a new Aged Care Act is sound and should as the Royal Commission stated; ‘ enshrine the rights of older people who are seeking or receiving aged care. This will leave no doubt to all involved in the system about the importance placed on these rights. A rights-based approach must guarantee universal access to the supports and services that an older person is assessed as needing.’

Such outcomes can only be achieved by a fit-for-purpose aged care system designed to enable responsive, accessible, affordable, resilient and sustainable service provision. The needs of older people are paramount but the strengthening of a network of quality, sustainable and ethical providers is fundamental to the rights of older people being given real meaning each and every day.

Critically, a reformed aged care system sits within a much broader public policy agenda regarding the wellbeing, welfare and safeguarding of Australia’s ageing population. A reformed aged care system will fail if all governments of Australia do not fully embrace a much wider set of responsibilities to older Australians.

An important lesson learnt from the introduction of the National Disability Insurance Scheme (NDIS) was the rapid withdrawal of services and supports for people with disability who were not NDIS participants by many state governments and the failure of the NDIS’s Information, Linkages and Capacity Building (ILC) Program to provide coherent, sustainable, capacity enhancing supports to people with disability generally. Many older people will not be part of the formal aged care system.

It is essential to understand that ageing is a gradual process, with increasing conditions that affect frailty, mental capacity and the need for services and supports, and increasing dependence on others. Formal aged care cannot meet all those needs, nor should it. Yet such needs must be met within a broader agenda of responsibilities of all governments and the community.

Whilst ‘Ageing in Place’ is now the cornerstone of our ageing strategies, it involves much more than the delivery of tightly defined services. Rather, it requires a holistic approach that has at its heart the dignity of the person, providing agency to the person and involves not only transacted services but relationships. It goes well beyond the provision of formal aged care services.

Whilst many older people acquire disabilities as they age and need significantly improved access to supports, it would be a mistake to believe that a wholesale adoption of the NDIS model is necessarily the solution.

The needs, aspirations, living conditions, carer arrangements, socio-economic circumstances of older people and the ageing process itself must be taken into account in building a fit-for-purpose aged care system unique to the needs, aspirations, and social and economic circumstances of older Australians.

These factors related to ageing and older people are different from those experienced by the cohort of recipients under the NDIS scheme, which is designed specifically for their needs and circumstances.

Given the progressive nature of ageing and associated frailties or impediments, programs and supports to provide early intervention, re-ablement, preventative services and social connectedness and inclusion are all essential to the wellbeing of older Australians.

They are and must remain the collective responsibility of all governments. Whilst many of these services sit outside the formal aged care system, they cannot play second fiddle to the formal aged care system, and are foundational to the success of any aged care reforms.

The financial circumstances of older Australians as a cohort are significantly different from people with disability, the latter generally having much lower incomes and wealth, especially for those that have acquired their disability at a young age. This is at the heart of the decision in the NDIS not to require co-payments in most circumstances. Whilst many older people have limited financial means, many others do have the ability to meet a portion of the costs of their aged care.

NDIS Learnings

The NDIS remains an impressive and essential reform which has greatly increased resources to the disability sector. Importantly, over 500,000 participants have benefited from a needs-based approach, acknowledging their individual circumstances, empowering their right to exercise enhanced choice and control and has brought about service and market-driven innovation.

Yet, there have been significant concerns and failures identified by many advocates, inquiries and reviews, which may be relevant when considering aged care reform including;

• A reluctance to address thin market failures in the design and implementation and a refusal to acknowledge grant funding models as permanent or interim approaches to address such weakness - especially in regional and remote areas, services for Indigenous people and cohorts of participants with highly complex needs.
• The raising of unrealistic client expectations in relation to the ‘reasonably necessary’ test for service funding and the inability to adjust individualised funding packages over time even when the packages are being underutilised or needs have diminished.
• The inclusion of social supports as part of the fee-for-service approach, causing unnecessary loss of service reliability and continuity, and limiting, not enhancing, social connectedness in some cases–though for some, new models of engagement have emerged.
• The failure of the ILC program and its administration to adequately provide sustainable, capacity-enhancing support and the unnecessary disruption to service provision.
• Overloading the system with complexity and legality, causing significant cost overruns and client frustration and leading to an unsustainable level of requests for reviews and appeals.
• A lack of adequate care/case management support, which should be readily accessible, especially for people with cognitive and intellectual disabilities.
• Workforce shortages remain a constant, even increasing, constraint on the NDIS scheme and its outcomes.
• A concerning level of fraud within the service provider market remains and raises questions as to the effectiveness of oversight measures.

Importantly, a significant issue was the protracted time to sort out the interface issues with state and territory governments around so-called boundary issues involving mainstream agencies such as health, education and transport. This leads to serious confusion for system operators and scheme participants. Further issues of funding for advocacy services still remain unresolved by the Department of Social Services (DSS) and other governments.

It is also now clear that there are very significant regulatory constraints and costs caused by the very large number of new market entrants. This rapid expansion of disability service providers is seriously testing the oversight regimes and there has been a significant lack of appreciation of the pressures such numbers of providers will impose on the system

Support at Home Program Overview

With respect to the Support at Home Program Overview, the thrust of much of the proposed reform follows the general intent of the Royal Commission recommendations. Much of the reform agenda will enhance consumer agency, if properly funded and administered respectfully and efficiently.

Yet, there are real concerns, especially in relation to the attempt to apply a marketised, individualised, fee-for-service approach to all of the supports to be delivered at home. There is not a sufficient reason for deviating from some key elements of the Royal Commission’s recommendations in relation to support at home, especially who should provide them and how they should be funded.

Further, given the lessons identified above in respect of other human services reforms, great care should be had in not repeating those failures, especially in the establishment phase.

In particular, whilst embracing a new common integrated assessment approach for support at home, a fundamental question is whether such assessments are absolutely necessary for all services, especially where the needs of the older person are very specific or very low.

Such a common assessment approach for many services, whilst meritorious, will significantly bring forward the demand for services by participants, and early decisions by assessors will lock in future expectations.

Additionally, the ability for the assessment process to allow for minor changes in the condition or circumstances of participants without the constant need for formal reassessments, within short time frames, will be essential otherwise the system will become overly intrusive and costly, and lead to significant demands for assessment reviews and appeal. The system must be able to accommodate changed circumstances easily, with little inconvenience or cost.

Consistent with the Royal Commission, several services identified should be provided by providers who are funded on either a grant funding basis or a combination of grant, activity or case mix funding. These include—Meals delivery and preparation, social supports, direct transport, goods equipment and assistive technologies and in home respite. There may well be other services better provided by way of grant, activity or case mix funding approaches.

There seems little benefit and many risks in including such services in a fee-for-service funding approach. Indeed, to do so is likely to disadvantage older people, unnecessarily disrupt community services provision and impact adversely the reform rollout.

Moreover, many of the current Commonwealth Home Support Programme (CHSP)providers should be actively encouraged and funded to continue to provide sustainable, reliable, consistent services to a large cohort of clients at least for the first 5-10 years of the reform roll out, when a thorough review could be undertaken of the reforms and their outcomes.

NDIS has shown considerable difficulties for service providers that provide supports on a congregate basis, including centre-based social programs, being funded by fee-for-service arrangements. Flexibility across a cohort of clients is essential to the operation of a number of service provision areas. Fee-for-service may work for some but not all service provision.

An overly transactionalised approach may crowd out relationship-building between people and communities. Relationships between people, not just with a worker or carer, are critical to the wellbeing of older people. The proposed reforms fail to adequately acknowledge the importance of relationships and capacity building to the wellbeing of older people, and to articulate a service system that would support such activities.

The University of Sydney through its Sydney Policy Lab has been undertaking a major research project to identify key components to a reformed model of caring in Australia.

The initial work identifies three essential components

• Dignity
• Agency
• Relationships

Any reform of the aged care system will need to specifically identify how such a reform incorporates these elements.

Many community providers under CHSP have excelled in such areas. The proposed reforms take little or no account of such aspects vital to the quality of life of older people nor the nature of organisations necessary to provide such supports over long periods.

Support at Home reform should be phased. The establishment phase should not seek to bring into the fee-for-service model the services recommended by the Royal Commission to be treated and funded differently.

If after a significant establishment phase, it is the considered view based on evidence that the range of services to be included should be expanded, then so be it.

But we should avoid trying to do too much, too soon and absolutely avoid an over-rapid expansion of market entrants which will overwhelm the regulatory safeguarding regimes and result in unnecessary churn of service providers with little benefit.

The mission or purpose, values and long-term commitment to aged care do differ amongst providers. Different organisations are driven by different incentives and long-term goals.

And different organisational types may be better at aligning the values of the organisation with the needs and aspirations of clients/consumers.

Whilst there is a ready acknowledgement that most aspects of human services may and should be delivered within a mixed market setting, there is increasing concern that this should not be universally applied to all service provision.

Further, it can be argued that to maintain the integrity of a market it is important to have a range of types of providers – government, not-for-profit, for-profit and mutuals. Both aged care and disability services lend themselves to this approach, and certain services within each system may be better provided by one or other of those types of provider. Some organisational types are better at aligning the interests of consumers with the interests of the organisations.

There is a need to acknowledge a different approach for thin markets and cohorts with special needs. In particular, there may need to be a special approach or pathway for older people who have experienced homelessness or ongoing trauma. A special set of grant-funded services will be needed. A separate well-funded stream or pathway is long overdue.

Equally special considerations may be needed for specific services for Culturally and Linguistically Diverse (CALD) communities taking into account the language and cultural aspects of older people from diverse ethnic communities.

Thin markets may in time prove to be less of a problem for aged services than experienced for disability services. Yet, thin markets do exist and must be carefully considered and addressed in the design phase. The failure to address thin markets in the NDIS establishment weakened the provision of accessible, quality, and reliable services for too many participants for too long.

Again the establishment phase should deal directly with thin markets. These thin markets may evolve and a mature market may deal with some of their issues in the long term. But it will be imprudent to try to apply a marketised model in the early stages in areas of genuine market weakness.

It is pleasing that the unique circumstances and needs of First Nations peoples and communities are acknowledged in the reform program. A First Nations pathway will require a well-funded, culturally appropriate service provision system, in which community and organisational capacity building is a critical component of any such program.

Transitional partnership models in which organisational and workforce capacity is built, with ultimate ownership being with First Nations peoples, should be developed as part of the reform strategy. Building community and organisational capacity is essential, yet it will take time and will require significant additional resourcing.

Treating the special needs of First Nations older people in a different manner will require increased resourcing and sustained commitment and attention. In the adoption of the Early Childhood Development National Quality Framework - Indigenous early childhood services were treated separately, but suffered from a lack of commensurate resourcing and attention, falling further behind the rest of the sector.

First Nations older people have every right to a quality aged care system that meets their needs and aspirations in culturally safe and appropriate ways. They have a right to competent, well-funded, well governed and appropriately staffed indigenous-owned and controlled organisations that meet their needs.

The above comments may seem overly negative or cautious. They may seem at first glance to diminish the argument for reforms in the care of older Australians and the aged care system in particular. Not so!

Aged care reform is necessary and desirable. And long overdue. Using the evidence of past reforms, both good and bad, will aid in the design and implementation of a new system of care and support. It will aid in developing an adaptable and responsive system of care and support which values emerging evidence.

Above all else, such learnings might ensure that reforms will genuinely keep the wellbeing of older people front and centre at all times.