Home | Industry+Policy | Tip of the iceberg? The neglect and abuse seen in residential care is simply the most visible part of a larger problem

Tip of the iceberg? The neglect and abuse seen in residential care is simply the most visible part of a larger problem

The Royal Commission into Aged Care needs to go beyond the urgent problems of residential aged care to look at the full formal system of care and support. We need to ensure we can increase staffing levels in residential care and ensure a high quality of care is available to all who need it.

To address the problems of abuse within the aged care system in Australia we must ensure that there are viable alternatives to residential care for as many people as possible. Only then can we prevent even larger disasters that are just around the corner.

Today the guiding strategy for aged care is set out in the ‘Aged Care Roadmap’, released by the Department of Health in 2016. The roadmap directs us to a path towards further deregulation and competition. According to the roadmap the destination is ‘A single aged care and support system that is market-based and consumer-driven, with access based on assessed need’.

Often, experience overseas will serve to guide the way. But in this case, there are no examples overseas where this approach has been shown to be successful. Nor have there been successful demonstrations of the approach in any region of Australia.

Given what we know already about the impact of other aged care reforms, such as the abolition of staffing ratios in residential care in Australia, how can anyone be certain the proposed reforms will work?

Many of the major moves have already been put in place and this gives us some insight into the potential outcome. One of the less publicised impacts to date has been the unintended effects of the introduction of consumer choice principles and new procedures for assessment.

Eligibility for all care at home, for example, is now formally assessed. Although it was previously possible to simply approach a Home Support service directly and be accepted for care immediately, the introduction of Consumer Directed Care (CDC) and the new assessment procedures have come at a huge cost.

Despite the massive expansion of the assessment program to take on the increased task, long waiting lists have developed. As Aged Care Insite reported at the time, official reports earlier this year confirmed waiting times of a year for CDC Home Care packages.

Instead of trying to funnel an additional 800,000 consumers who use CHSP (the Home Support Program, previously called HACC) services into a single assessment program designed for 90,000, might it be better to think of the CHSP as a low-cost tier of primary care service which consumers can approach directly, just as we do with GPs and dentists?

Is it desirable to proceed with the planned reforms and effectively collapse the CHSP into the Home Care Program to produce a single system? The move, which will see the block funding of CHSP services replaced by fee-for-service payments under which they will compete with Home Care Services, is now scheduled to take place from 2020. It was previously scheduled for 2017 and then 2018, so perhaps there is some trepidation about the move at the Commonwealth level.

And what will be the impact on the non-profit, block-funded CHSP services? Will the volunteers continue to work without pay when a fee-for-service payment is in operation?

There are many other existing and potential problems that require attention, including the new approach that sees carers as a consumer group, that is quite distinct from the aged care consumers.

If we want to prevent the even larger disasters that are just around the corner, there are alternatives to residential care. We must ensure these are viable, sustainable and available to as many people as possible.

The roadmap suggests we are currently heading towards even greater problems. One thing is certain: we need the Royal Commission to go beyond the urgent problems of residential aged care to look at the problems of the full formal system of care and support.

Michael Fine is an honorary professor in the department of sociology at Macquarie University.

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  1. Tip of the iceberg indeed. I agree wholeheartedly but can anyone tell me exactly what is the alternative to the eventual reality of residential care?
    Home care will soon be proven to be unsustainable, it certainly doesnt deliver any quantity of care for the massive sums thrown at it. But lets forget about the huge financial cost of home care and lets look at the other cost apparently being ignored by the boffins.
    Ive been an approved provider of residential care for over 30 years and the system today is the worst it has ever been. But the emotional and family quality of life cost of keeping a seriously impaired senior at home is often disastrous and ignored by the law makers. The amount of times I have had families come to me on the brink of divorce,separation, depressed, health problems of their own, resentful grandkids because mum and dad cant go to sport, the pictures etc etc…well I cant count…and this has come about by having an elderly nan or pop dependent needing 24/7 care.
    This cost is very real, not many would choose to live in a facility but its what we call reality. Most of us are living longer and longer doesnt always equal living better. Residential aged care is grossly undervalued and this has been exacerbated by the media storm of late but like it or not there is a very real need for us and that need will undoubtedly grow, not shrink.
    And finally, despite what you see on TV the very vast majority of people in care are being cared for very well by some of the very best humans anywhere. A few rotten apples are always in the bag unfortunately.

  2. I have been looking at the marketisation of health and aged care nearly 30 years. Michael, that is a great article, and the sooner we can scrap the pie in the sky roadmap the better. I do worry that some in the community will be vulnerable to exploitation and abuse if we continue down that road.

    Anton this is not a few bad apples or just lack of money. Its system failure. It has been going on for a long time, not only in Australia and not only in aged care. We will get nowhere until we accept that. You do make a very good point about the burden that home care can become for families. I think most of us would want to spare our families this even if it means some sacrifice. So we need to address both areas and the roadmap prevents us from doing that.

    Ultimately it is every one of us and our community that is responsible for the care of the vulnerable. Government and industry are incapable of addressing this alone. As Michael has indicated elsewhere most of us have 15 to 20 years of active life after we retire. We are capable of organising ourselves and getting involved.

    We are pressing for an empowered local visitors scheme working closely with local groups of more knowledgeable community members to oversee and manage aged care locally and work out sensible solutions with providers. To be effective a market needs empowered customers and a community to set and enforce the limits of acceptable conduct. Consumer vulnerability places much greater onus on community. It is government’s role to support and build civil society and the communities that comprise it – not assume its functions. Academics have an important role and need to contribute with research and insights.

    Aged care occurs at the bedside in our communities and that is where sensible care and policy decisions should start – not in board rooms or corridors of power – or with an excess of depersonalising government process and regulation.

    • What a great comment Anton. The packaged care model was a valuable add on to the system when it was introduced, but to make it the ‘single system’ identified in the Aged Care Roadmap has been a major mistake. Don’t get me started on the new assessment gateway, etc.

      It’s important that we work to make the Royal Commission a real opportunity to review and scrutinise the problems in the existing system, and use it to help redesign the way forward. I think we need a new roadmap to start with.

      I agree with you about residential care. We know how to do it well now (small scale residential units, with mandated minimum staff ratios, quality improvement systems, serious inspection and complaints procedures, etc.) But to do so we need less of it, not more, as a way to keep it affordable. We also need to develop and extend it’s purpose as a slow stream rehab program with day care and much more community engagement.

      The old HACC system showed us how efficient a block funded system can be. We need to re-purpose that as a form of primary community care – no referral necessary.

      And I agree. Lets stop blaming the people who work in the system. It is full of great staff and family carers. Lets celebrate them and work with them to make it better.

  3. Michael, you’ve put it well. Lets redirect the roadmap from the current destination – marketisation, and back towards community building and shared responsibility with a strong government role – not just in funding. The idea of ‘choice’ sounds nice, but as you point out, it is not always possible for people at the point of highest need, to make rationale informed choices or to be in a position to follow up the administration or foresee the personal and financial consequences of these decisions.

    We had a community visitors scheme that worked very well – especially in terms of the resources invested in it.