Home | Industry+Policy | Personalised budgets in home care: Can market-driven care deliver quality?

Personalised budgets in home care: Can market-driven care deliver quality?

Two years after the introduction of personalised funding in the home care sector, the evidence of its impact of increasing choice, control and quality through competitive markets is mixed. Research commissioned by the Department of Health to evaluate the experiences and perceptions of home care package among consumers and service providers since the Increasing Choice in Home Care reforms showed that the mix of services older people use and the providers delivering them remain mostly the same. The bulk of services older people receive are for basic support, including domestic support, transport and personal care, and the choice of provider is greatly determined by availability and a preference for continuity of service.

Research on the experience of consumers with personalised funding conducted by the University of Queensland in 2018 found that while people were happy with being able to choose providers, there was a significant level of frustration about the lack of flexibility once services were delivered. This included ability to make changes to care plans for activities such as providing gardening or some equipment that was not initially identified. There is now to some extent less ability to respond to emergent and unassessed needs. These issues are to some extent the unintended consequences of personalised budgets where the goal of care shifts from responding to consumers’ needs to providing care based on standardised packages. The study also found dissatisfaction among consumers due to lack of information, poor communication, staff inconsistency and having to wait for services, as well confusion over the My Aged Care website.

The current waiting list for high level care also tells us something about the model. More than 95,000 people with high needs are waiting for a level three or four package with almost 17,000 of these not receiving any support at all. With the waiting list growing by almost 4,000 in just three months, the 3,500 new home care packages a year committed in last year’s Budget won’t come close to keeping pace with demand. The fact that people deemed eligible for high to very high levels of support are not receiving care or the care does not meet their current needs is an indictment on the current funding model. Under the previous model of block funding, older people may not have had the ‘choice’ they have now, but they were in their majority accessing services and having their critical needs met. The block funded model also allowed service providers to spread funds to provide additional support for people whose care needs changed.

From a quality perspective, a key measure to determine the merit of the reforms in home care is the extent to which it achieves its main objective of supporting older people’s independence, health and wellbeing, and their ability to remain at home. The evidence shows that personalised budgets have for some improved their ability to make choices regarding their provider and they are more likely to report feeling in control of their daily lives. This is a key attraction of the rhetoric of personalisation – its claim to offer both choice and control via the mechanism of a direct payment or individual budget. However as pointed to above, the bulk of evidence, including research and evaluations commissioned by the Department of Health indicate an overall reluctance to change providers. On the other hand this benefit is not being equally available to all. Those on waiting lists are missing out, as well as older people receiving services that partially meet their needs. Older people from disadvantaged groups including Aboriginal and Torres Strait Islander people, those from culturally and linguistically diverse backgrounds, the poor and those living in remote communities are missing out, and not because of language barriers or cultural preferences but because when it comes to purchasing social care they are ineffective consumers. A report to the United Nations Economic and Social Council defines ‘disadvantaged’ as those groups that encounter structural obstacles (i.e., obstacles created by society) to access to resources, benefits and opportunities. Those obstacles derive from the relationships of power that exists in all societies and the relative value that society gives to each group. The structural causes that underlie disadvantage include race, ethnicity, gender, religion, indigenous or national origin and socio-economic status.

As pointed out in a Consumer Affairs Victoria report on consumer disadvantage, the two major dimensions of consumption are the market dimension and the personal dimension. When it comes to aged care, the market dimension includes complex products and transactions, control of information by suppliers, marketing strategies, etc. The personal domains include literacy levels, level of trust, negotiation skills, impairment, levels of education and resources. Calls to better support older people who are disadvantaged through better information and better resources fail to recognise the pervasive and enduring impact of poverty, limited education, limited literacy, remoteness, disability, trauma and neglect on the ability of older people to seek information, compare products, negotiate services, reassert their individual rights and make complaints.

Older consumers with normal capacities and in ordinary personal circumstances may still be vulnerable to market-driven care, due mainly to the complexity of the products being sold and the risks associated with making choices with such profound implications for their health, wellbeing and quality of life under stressful and time-pressured circumstances. Older people from disadvantaged groups face the above plus the compounding impact of constrained capabilities and adverse circumstances. The response from the government to consumer vulnerability has been through recognition of the importance of strengthening consumer protections rather than reconsidering the merit of a market-driven care model. This is evidenced in the 2017 Review of the National Aged Care Quality Regulatory Processes in response to the Oakden scandal, which recommended various strategies to strengthen the protection of consumers in residential aged care while leaving intact the tenet that aged care is like any other good or service and it is best produced and distributed through markets.

Two key points here are that making personalised budgets, or consumer directed care as it is called, in itself, does not guarantee increased choice and control for older people. Other factors including the size of that budget, the vulnerability of purchasing a product in time of crisis, the market dimension and the personal domains play a crucial role.

Secondly, market-driven care is not a guarantee of quality through competition. The question of whether marketisation and for-profit provision of care are positive developments for citizens and the care labour force has been the focus of empirical research internationally. The evidence, not only in Australia, but in the UK, Ireland and Europe needs careful consideration. National and international research into aged care in England, Sweden and Australia has found no firm evidence that increased competition and marketisation increases quality or lowers costs. On the contrary, they have been associated with increased inequalities among consumers, high staff turnover and lower ratios of staff to consumer in residential care as well as lower quality of care. In Norway, resistance to markets has been strong and has led to the development of innovative system-wide alternatives to competition, including cooperation and community participation in the protection of consumers, planning and implementation of eldercare protect while legislating protections for the non-profit institutions from the effects of marketisation.

As the royal commission uncovers more examples and evidence of malpractice, neglect and poor care in institutional care it is important to reflect on the ongoing crisis in the home care sector. We need to question the manner in which the rhetoric of choice, control and independence associated with personalised budgets has silenced the less attractive attributes and consequences of making social care a market product for frail older consumers despite considerable vulnerability and disadvantage when it comes to purchasing care.

Dr Beatriz Cardona is a research fellow at Macquarie University and sector support worker at The Multicultural Network.

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  1. Really why would we be surprised that neo-liberal, market-based solutions are no more successful in aged care than they have been anywhere else? It all sounded good in 2011 but now?

  2. Hi Dallas,

    Your comments about budgets and choice are accurate and timely.

    My own Mum, over 5 years ago, desperately needed services at home after leaving hospital. At first I found it difficult to obtain information… there were hospital outpatient services, local council services, and federal government services that pre-dated CHSP and HCP. Nobody gave me a clear picture of the funding / services landscape. I had to piece it together by talking to many people.
    Once Mum was off the waiting list and on a package, she transitioned from Council services to her (what is now) HCP Home Care Package. Our In-Home Service Provider’s Case Manager did a FANTASTIC job. I never once thought that we were limited in our choice, or that the Case Manager had to do the choosing for us. Over the 2-3 years, we had many great meetings/conversations and juggled the funding and services to cover various services and products including nursing care, showering assistance, gardening, cleaning, food/food preparation, outings, chairs, hand-rails, grab handles, assistive technology* and more. My point is that the Case Manager ALWAYS made it clear that it was our choice. So when CDC came along, I was quite puzzled. Hasn’t it always been this way?

    If there had been a Seniors Video Phone available back then, I would’ve bought one for Mum as part of her package.

    The media exploded last year with reports of aged-care abuse and neglect, resulting in the Royal Commission and, at least indirectly, the new Aged Care Quality Standards. Now, abuse makes me angry and it is an important issue. Very important. However… the LONG waiting list makes me much, much more angry. This is abuse at another scale. As a country, we are abusing and neglecting our elderly population. We are promising them funding that will help them remain at home longer, which (in turn) saves costs — fewer tax-payer funded hospital admissions, fewer or delayed tax-payer subsidized aged-care home admissions, and fewer carers (sons and daughters) stressed and unable to work due to the load carried on their shoulders.

    My point is that the long waiting lists are shortening lives, taking family members away from being productive citizens, and costing the tax payer much more than the savings in packages (funds).

    Perhaps what we need are a few juicy stories that the media will latch onto, about “victims” of waiting lists?

    I’m SHOCKED that neither major party is making this an election issue. I read somewhere that 12 percent of Australians are, in some shape or form, care providers. Surely that’s a large voting population that would swing an election result?

    Thanks for your article.

  3. An excellent analysis which shows why we need to reconsider CDC. Older people are not able to search and access the services they need and they are missing on essential support. Those who are lucky to receive support are not having the quality of services promised to them under consumer directed care. Not everything can be addressed through business models, specially when it comes to fragile and vulnerable people and the government needs to realise this.