Home | Industry+Policy | Three cheers for tiers: in aged care one size does not fit all

Three cheers for tiers: in aged care one size does not fit all

Here’s a simple idea for the Royal Commission into Aged Care Quality and Safety.

Let’s try and assist as many older people as possible to stay at home to receive their care.

To help this along, we should try to make access to basic support services simple and easy, not difficult. Let these basic services do what they can to enable and re-able people to remain at home. And if they can’t, consumers can be referred on to receive more complex care at home, or in very complex cases, to residential care services.

Instead of trying to force the entire aged care system in Australia into a single pathway, as the Aged Care Roadmap attempts to do, perhaps we should consider the merits of a more cleverly differentiated approach.

After all, it is only through pursuing the simplification that a single unified system entails, that we have got ourselves into a mess involving waiting lists of 12 months and more for a home care service, and long waiting times for assessment that hold up any access to support provided at home.

The Roadmap, published in 2016, is clear in that it seeks a simple, single aged care system, spelling out its goal of producing what it describes as “a single aged care and support system that is market based and consumer driven, with access based on assessed need”.

This, in turn, requires appropriate assessment procedures, and so the Roadmap outlines the goal of introducing “a single government operated assessment process”.

You’ll note how this single system is exactly the opposite of the systems logic we employ in healthcare. In line with the recommendations of the World Health Organization, healthcare in Australia and elsewhere is clearly divided into three tiers.

Imagine the difficulty and cost if every time you needed to use primary care – to visit the GP or the dentist for example – you first had to go through a single government-operated assessment process.

The logic is to deal with the greatest number of problems possible at the most basic, cheapest, most cost-effective level. That’s why it is called primary care. This enables the much more expensive upper tiers of the system to provide more intensive and specialised professional support to much reduced numbers of people.

The referral and funding process in the healthcare system continues to be contentious. Nevertheless, one point of agreement is that access to the second and third tiers needs to be on the basis of careful referral and assessment, a process based on referrals from GPs and other primary care practitioners.

Using our imagination, we can take a quick tour of other comparable areas of public responsibility. One example that springs to mind is that of the law. Of course, there is only one set of laws and these apply, more or less fairly, to everyone in the country. But the mechanisms for applying that law are quite complex and differentiated.

Think of the problems that would be involved if every ‘offence’ was treated as requiring adjudication in a court. Of course, if you’d like to dispute a traffic fine or other minor punishment, you can go to court. Similarly, magistrates deal with many of the more complex lower-level legal issues, restricting the use of full trials with judges and juries to cases likely to result in serious criminal punishments.

Now imagine that older people who needed advice or some basic support were simply able to approach their local Home Support Services and ask for help. If they needed more than that service could provide, they could be referred on, and perhaps wisely, receive a serious and professional assessment.

The number requiring assessment would be considerably less than the number requiring one now. I suspect we’d see much reduced waiting lists for home care packages.

Amazing, isn’t it, how some of the elements remind you of the system we had just a couple of years ago, before waiting lists blew out and support became difficult to access, as it is today?

What we need is a more fundamental rethink that will enable the Home Support Program to become a full primary care program. We need to develop staff skills and careers and back them with a different funding system to the competitive assessment and activity-based fee system proposed.

If we keep going to the destination set out in the Roadmap, we will surely drive both the waiting lists and the cost of aged care up, not down. Long waiting lists for home support will also have the very predictable consequence of increasing admissions to residential care.




Michael Fine is an honorary professor in Macquarie University’s Department of Sociology.

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  1. Hi Michael – you are so correct with this view – but as we all know Primary healthcare has always been elusive as its been hard to provide the data on its true outcomes. Well not anymore – with Big data, AI and the collection of outcomes over a lifetime we can now clearly show the link between primary carer programs and their reduction on the impost on tertiary care. Lets take Denmark for example where they have stopped building hospital yet we keep building more and more (and even more expensive). We are we as a country shying away from pushing the value back down the other end end of the service chain to support people to remain living independent at home for as long as possible??

    • Luke,

      Thanks for your very astute reply. I’m not sure it is just data – although you may be right about it contributing to the problem. I think your final question/comment is spot on! The market approach seems to be to indicate that it is desirable to provide the most expensive model possible. Hence the idea of demolishing the Olympic Stadium in Sydney, to replace it with another, at a cost of $2b, was seen as sensible in NSW politics. I think it is the same with the preference for spending on residential care and CDC packages instead of CHSP.