COTA's response to Healthy ageing strategy

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COUNCIL ON THE AGEING (AUSTRALIA)

Response to Healthy Ageing

discussion paper for the

National Strategy for an Ageing Australia

 

Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent
Melbourne Victoria 3004
Phone: 03 9820 2655
Facsimile: 03 9820 9886

Email: cota@cota.org.au

FEBRUARY 2000

 

Contents

INTRODUCTION

PART ONE:

A FRAMEWORK FOR HEALTHY AGEING AS PART OF THE NATIONAL STRATEGY FOR AN AGEING AUSTRALIA

PART TWO:

A NATIONAL STRATEGY FOR HEALTHY AGEING IN ABORIGINAL COMMUNITIES

Healthy Ageing

INTRODUCTION

COTA's original concept of the National Strategy for an Ageing Australia, presented to the Government in March 1998, proposed three tiers of action:

1. Level one: the broad economic, social and environmental context. The capacity of Australia to successfully manage an ageing population in a way that is fair, equitable and sustainable will depend to a very large degree on the following factors: a sound economy with low levels of unemployment, sustainable growth and low levels of income inequality; a stable and harmonious society characterised by intergenerational respect, racial tolerance, gender equity, and fairness in the distribution of resources; a physical environment that provides for a high level of amenity and public health. For example, high levels of air pollution create respiratory and other illnesses. Environmental sustainability is also a corollary of sustainable economic growth.

.2. Level two: the community context. The ageing of the population will also be most successfully managed if the community settings are appropriate. In this layer of policy action the following factors are important: community and urban planning transport. housing social and cultural amenities

3. Level three: the program context. This level of policy action covers areas over which governments are able to dedicate specific expenditure for specific purposes. Some of the major areas relevant to the National Strategy for an Ageing Australia: retirement incomes health and health services residential aged care community care housing education and training

IMPLICATIONS FOR A NATIONAL STRATEGY ON HEALTHY AGEING

Healthy ageing for Australia's population demands that the Government attends to action in all of these areas. Our submission therefore departs from the implied parameters of the healthy ageing discussion paper which we believe are far too narrow to be meaningful in terms of a strategic policy framework for an ageing population.

COTA's starting point for the development of our strategic approach is the definition of healthy ageing provided on p 3 of the discussion paper:

healthy ageing is an individual, community, public and private sector approach to ageing that aims to maintain and improve the physical, emotional and mental well-being of older people. It extends beyond the health and community services sectors as the well-being of older Australians is affected by many different factors including socio-economic status, family and broader social interactions, employment, housing, and transport. Social attitudes and perceptions of ageing can also strongly influence the wellbeing of older people whether through direct discrimination or through negative attitudes and images.

Also relevant to the definition of healthy ageing is the United Nations view (page 3 of the discussion paper also):

of ageing as a lifelong process (which) focuses on improving the wellbeing of people as they age.

These definitions serve as our starting points for developing a National Strategy in the area of healthy ageing.

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PART ONE:

A FRAMEWORK FOR HEALTHY AGEING AS PART OF THE NATIONAL STRATEGY FOR AN AGEING AUSTRALIA

Level one: the broad economic, social and environmental context

In COTA's policy framework healthy ageing starts with the fundamentals.

A sound economy with full employment, sustainable growth and low levels of income inequality.

Healthy ageing and the capacity for individuals to enjoy a good quality of life as they age will almost always relate to the level of economic stability, prosperity and equality enjoyed in a society. Life expectancy and level of disability and handicap for a population are linked inextricably to economic factors and standard of living as pointed out in this recent publication from the Department of Health and Aged Care:

It is beyond question that illness occurs more commonly amongst those people living in poverty than those with greater social and economic resources. The association between socio-economic disadvantage and health status is one of the strongest, most durable and most universal in epidemiological research (Leeder, 1993). Health inequalities related to social or socio-economic status have been established in all countries that collect the data…(Hupalo and Herden, 1999, p1).

COTA believes that the healthy ageing project, as part of the National Strategy for an Ageing Australia, must be prepared to make this analysis a starting point for a long-term policy and planning process. It is a major omission that there has been no discussion of the implications of poverty in Australian society for healthy ageing in the background paper. This omission should be addressed in the development of the National Strategy. COTA believes that the association between socio-economic factors and healthy ageing are so important, that we have prepared a special section with respect to healthy ageing in the Aboriginal community (see part two of this submission).

Healthy ageing starts with sustainable economic growth which is the basis for income generation, the key determinant of the standard of living enjoyed by a society. Income must be then distributed equitably through the community. For the majority of the population wages from employment and payments through the social security system will be the most important means of securing income. Both these mechanisms are discussed below.

Employment and healthy ageing

COTA particularly wishes to emphasise the importance of employment for healthy ageing outcomes.

There is a strong correlation between economic well-being and health status across all age groups, no less for older people. However, when lack of opportunities for paid employment interrupt the income generation process in the middle years, there are profound implications for the level of income for old age and retirement. This in turn can have a profound effect on the opportunity for healthy ageing.

One of the most important pillars for healthy ageing is an adequate income and sound asset base for the post retirement years. For most people security and a comfortable lifestyle in retirement are based on what they are able to save and invest while they are in paid employment. The chances for an individual achieving healthy ageing, however, can be seriously compromised by circumstances in the pre-retirement, middle years.

There are significant numbers of people in their middle years who are missing out on opportunities for saving and investment at this critical time. The reasons for this are complex. There has been high unemployment for a long period of time such that job opportunities are scarce relative to job applicants. However, for mature age people, age discrimination is an important factor in terms of retaining and gaining jobs.

According to the Department of Family and Community Services (1999), 46 per cent of people aged between 50 to 64, are not in paid employment. Currently around 33 per cent in this age group receive some form of social security payment compared to 26.8 per cent in 1978. While social security incomes are set at modest levels to ensure a subsistence standard of living, they do not allow for savings for long term needs.

For many people in their middle years, long term reliance on a social security income will usually mean erosion of their asset base. Without a job, and without a solid assets base, middle-aged people quickly drop in economic status. In turn this can mean a fall in health status. The links between socio-economic status and health status have been long established (see for instance review of the literature in McClelland, Pirkis and Willcox's, Enough to make you sick). It is also a point discussed in some depth in the recent Department of Health and Aged Care paper by Hupalo and Herden (1999).

Much job loss amongst mature age people appears to be associated with ill health or injury. The Australian Bureau of Statistics (ABS) publication, Retirement and retirement intentions, released in June 1998 shows that "own ill-health or injury" is the reason given for retiring from full-time work by 37 per cent of males and 19 per cent of females aged between 45 and 64.

It is likely that ill-health or injury is often a surrogate for social reasons for leaving workplaces where the older worker is neither valued nor encouraged, especially during organisational restructuring and downsizing. It is also likely that negative work environments contribute to health problems for mature age people. A key message of the Royal Australasian College of Physicians' report (1999), For richer, for poorer, in sickness and in health: the socio-economic determinants of health, is that stress is a major cause of ill-health. This report specifically mentions the negative impacts on health created by unstable workplaces and powerlessness within the workplace.

COTA speculates that many mature age people with relatively minor illnesses and injury retire because of their perceptions that their employment prospects are extremely limited. For many mature age people this means long term reliance on disability pensions. According to a the Department of Family and Community Services (1999), 55 per cent of older working age men and 15 per cent of older working age women, receiving a social security income are on a Disability Support Pension. There has been a steady increase in reliance on this income support payment. In 1987, 12 per cent of all men and 3 per cent of all women between the ages of 50 and 64 received this payment compared to 15 per cent and 6 per cent respectively in 1997.

COTA argues strongly that employment is a vital underpinning of healthy ageing without which other areas of interest to the healthy ageing project will be of significantly less value.

Social security and healthy ageing

The social security system plays a vital role in alleviating poverty and ensuring that those Australians unable to garner income from employment or other private sources, have access to a basic income in order to be able to live decently.

For most older people, the Age Pension is the primary source of income. For people below the pension eligibility age, income security payments include unemployment benefits, disability pensions and carer pensions.

COTA holds the view that social security payments must be set at levels to ensure that individuals are able to have a standard of living broadly commensurate with prevailing social norms.

COTA's concerns regarding the adequacy of social security payments for some groups of older people The Social Policy Research Centre research (Saunders et al,1998 Development of Indicative Budget Standards, Social Policy Research Centre, Policy Research Paper No. 74) showed that for a single older person renting privately, their income from the age pension would fall some 35 per cent below what they needed for a "low cost budget standard" which is characterised by the Social Policy Research Centre as:

one which may require frugal and careful management of resources but would still allow social and economic participation consistent with community standards and enable the individual to fulfil community expectations in the workplace, at home and in the community. It describes a level below which it becomes increasingly difficult to maintain an acceptable living standard because of the increased risk of deprivation and disadvantage (Budget Standards Unit, Newsheet No. 4, May 1998, p3).

The pension income of a home owner, without private income would be some 20 per cent below the "low cost budget standard" and the income of a public housing tenant would be around 7 per cent below. While there has been some controversy over the Social Policy Research Centre's methodology in calculating the budget standards, COTA believes that the research findings reflect the experience of hardship and difficulties in managing reported to us by older people – in the main, single people in private rental or in owner occupier housing, fully reliant on the age pension with no other sources of income.

COTA is most concerned about the long term health effects on many of these people who are subject to a high level of stress and social isolation as a result of inadequate income.

In addition, there are a range of income support issues for mature age people between approximately 50 years old and age pension eligibility age. As noted above 33 per cent in this age group are reliant on an income support payment.

Of particular concern to COTA are those people on unemployment payments – Newstart Allowance – which is a payment set considerably lower than the age pension. Unemployment payments were originally conceived as short term payments for people in their transition from one job to another – 30 years ago this would have been a matter of weeks. But for people over 50 the average duration of unemployment is 2 years. This is a very long period to be surviving on an income that is well below the level of the pension. We advocate lifting the rate of payment of Newstart Allowance to that of the Age Pension.

COTA has concerns about the high level of dependency on income support payments amongst the 50 to 64 age group and the impact of this on savings for retirement and older age. We believe that the lack of employment opportunities and age discrimination in the Australian workforce are compromising the healthy ageing prospects in this group. The long term solution is improved employment options but for the short to medium term, adequate income support through the social security system must be available.

COTA believe that income support issues vis a vis paid employment and the social security system are a vital part of the healthy ageing project.

A stable and harmonious society characterised by intergenerational respect, racial tolerance, gender equity

Healthy ageing for the Australian population will be contingent on a range of social factors. While economic prosperity and stability are very important, they must be linked to qualities of fairness and equality of opportunity, by social security and harmony across racial, generational and gender lines.

COTA believes that the potential for healthy ageing is reduced in a society characterised by conflict, inequality and low levels of perceived and actual security.

A positive outlook and attitudes on ageing and older people is a vital element in the nurturing of healthy ageing. Older people also need to be perceived as a diverse group, as diverse as the population as a whole.

A physical environment that provides for a high level of amenity and public health

At the most basic level clean air, water and food are mandatory conditions for healthy ageing.

In many parts of the world, the potential for healthy ageing is compromised by serious deficits in these areas due to uncontrolled industrial development, poor agrarian practices and/or a very low national income per capita.

However, globally there are significant dangers to healthy ageing from which no one will be immune. For instance ozone depletion will result in an increase in the incidence of skin cancer and global warming has been linked to the development of viruses from which humans have no or little immunity. Already, Australia is a record holder in the incidence of skin cancers.

The type of dangers to healthy ageing that are most relevant in the Australian urban and rural contexts are the following

• air pollution from excessive use of fossil fuels for energy for private transport and industry
• pollution of water supply due to agricultural practices, dumping of waste at sea and other poor environmental practices
• contamination of land due to the dumping of toxic wastes

While environmental policy is not a well-developed area of COTA policy, we are of the view that it is fundamental to the healthy ageing project and look forward to this being a prominent feature of the National Strategy.

Level two: the community context

The ageing of the population will also be most successfully managed if the community settings are appropriate. In this layer of policy action the following factors are important:

Community and urban planning

The physical layout of communities and cities is vitally important to promoting healthy ageing. Urban structures need to be developed which maximise the independence and mobility of older people. COTA believes these are important for the well-being of an ageing population.

Older people need to live in communities and urban settings that are sensitive to their needs for access to shops, facilities such as swimming pools, libraries, education and other services. As people grow older and become less mobile their lives become more focussed on their immediate surroundings. Places within walking distance may become more important to them, than those accessible by car or public transport.

In addition, it is important to recognise that rural Australia has an ageing population. Community and urban planning, housing and transport planning need to adapt to local conditions

The nature of housing and transport systems are vital components of the urban planning process as discussed below.

Transport

Transport that is affordable, accessible and structured to meet the travel patterns of seniors can do much to enable involvement and participation, as well as contribute to improvements in quality of life. These are important components of healthy ageing.

While driving a private car is an option for some older people, it is not an option for many especially for people in the older age groups. Accessible, affordable and appropriate public transport is needed for older people to ensure that they can take advantage of community facilities and services.

COTA believes that governments should be reinvesting in public transport by developing innovative strategies to meet transport needs at a community level; evaluating ways in which the existing system is meeting these needs; and adjusting it where necessary.

Much better integration and coordination of public transport is required, for example, between, bus and rail services to improve route designs within and across suburbs and in rural areas, and to improve service frequencies and connections.

Good public transport systems in conjunction with a greater emphasis on urban villages and higher density land use could begin to address the problems of social isolation and over-dependence on cars which erode the quality of life of older Australians.

The specific transport needs of older people in rural and regional Australia needs to be considered. Flexible, affordable, and accessible community transport options need to be developed to ensure that the opportunities for older Australians outside the metropolitan areas have opportunities for social opportunities and are able to access the services that they need.

Housing

COTA believes that a range of policies and program responses are needed to cover the diversity of housing circumstances and needs of older people. The broad divide in terms of need for housing assistance is between people who own a house and those who do not.

It is well established that older people in private rental accommodation are the most disadvantaged amongst older people. However, owner-occupiers also need housing assistance. Some of these needs relate to the low exchange value of their homes, high maintenance costs and barriers to relocation.

The housing circumstances of a person in older age have immense effects on their quality of life and well-being, health status and life expectancy. Therefore housing is a vital consideration in terms of a healthy ageing strategy.

Older people need housing that incorporates a number of elements. COTA's selection of the most important of these are derived from those stated in the Commonwealth-State Housing Agreement and consist of accessibility, affordability, appropriateness, security of tenure and equity. (Industry Commission, 1993, p10). We discuss each of these principles in terms of their application to the housing needs of older people.

Accessibility: For older people accessibility means being able to enter the type of accommodation that is most suitable for their stage of life and physical, social, cultural and psychological needs. It also incorporates the idea of accessibility to the services and amenities, relatives and friends that are important in maintaining the quality of life of older people need and use.

Affordability: The Council on the Ageing considers that a benchmark of 25 per cent of income for housing costs is the most appropriate one for ensuring that older people, who are reliant on the Age Pension and are in public or private rental accommodation, have enough income left over to ensure an adequate standard of living.

Appropriateness: For older people appropriateness embodies a number of concepts:

• physical access especially for people with reduced mobility
• ease of maintenance
• suitability in terms of space, design and amenity of the accommodation
• location and access to friends, family, community and services
• privacy and security

Security of tenure: COTA is of the view that in old age, people should not need to worry about having a roof over their heads. They should be able to feel that they can stay in the one place for as long as they choose or until care needs make independent living impractical. 

Equity: COTA is of the view that there is a hierarchy of need for housing assistance for older people. The highest level of need occurs amongst those who are at risk of homelessness and/or those who are renting privately.

Residential care, retirement villages and ageing in place

COTA believes that as far as possible older people should be assisted to remain in their own homes or, otherwise, familiar communities but in a different form of housing – the concept of ageing in place. While exclusive domains for older people may have some merits, our work in South Australia in the Youth-Seniors project, points to serious problems emerging regarding older people who live only with other older people and are isolated from other age groups in the community.

In the Youth-Seniors Project, the young people involved felt that older people are cut off from the rest of the community by living in retirement villages with walls around them. There are also concerns that older people who live in residential care are not viewed as part of the community. Healthy ageing housing strategies should encourage sharing, co-location and integration between the generations not segregation. This will be even more important as more people find themselves living alone or choosing to.

Diverse communities encourage intergenerational respect and tolerance. Young people eventually grow old and their healthy ageing will depend on the promotion of a positive outlook on older people and the ageing process through continuous contact with older people in their local communities.

Needless to say, for people who eventually must go into residential care, where community care is no longer a viable option, high quality services and high standards are critical.

Social and cultural amenities

Healthy ageing will be supported by older people's access to social and cultural amenities and participation in the life of the community.

It is critical that the "social capital" of the community is developed to ensure that the potential for self-fulfillment and opportunities for active, stimulating engagement for people as they age is maximised.

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Level three: health program context

Health financing

The provision of adequate health services is unquestionably a critical dimension for the achievement of healthy ageing. The relevant issues are the overall levels of expenditure to meet the needs of an ageing population and the allocation of those resources.

COTA's view is that a universal health system has immense advantages in both equity and economic terms over a privatised system along the lines of the US system. By having a system that is accessible to all, we all have an interest in the continuous improvement of its quality. A universal system means that whether or not you are rich or poor, you will receive the same standard of treatment.

In addition, a universal system keeps costs under control - Medicare has the purchasing power and price control mechanisms to ensure taxpayers get the best deal in health services.

Australia currently spends around 8.5 per cent of GDP on health services per annum which is about average for the OECD. The growth in cost for health care over the last twenty years broadly tracks that of other OECD countries with the exception of the United States where health expenditure has grown at a much faster rate than any other OECD country (AIHW,1998, p169).

There has been considerable concern about the effects of the ageing population on the costs of the health system.

The call on health services is concentrated in the last two years of life, when people are most ill, compared to any other stage of life. It is to be expected then, that most health expenditure will be concentrated on the aged. As illness and death have progressively been relegated to older age groups due to advances in medical technology and higher standards of living, there has been commensurately a growth in the cost of providing health services to this group.

In reality, population ageing contributed less than one-fifth of the annual real increase in health outlays over the last twenty years: that is an, estimated 0.6 per cent a year in real health outlays growth. Equally, it is expected to add 0.6 per cent a year on average over the next twenty years (Podger, 1998, p8).

Clearly we need an adequately funded health system to ensure that Australia is able to provide suitable health care for all regardless of age or ability to pay.

We would see the following as being the essential features of a health system that promoted healthy ageing:

• provision of swift and technologically up-to-date medical interventions in the event of medical emergencies

• provision of timely quality-of-life enhancing treatments such that people do not have to live in pain and discomfort because of excessive rationing in the health system via waiting lists

• a system that is well-coordinated between primary care, acute care, post-acute, palliative care, health promotion, allied health, community care and other relevant areas of the health system.

• access to new pharmaceuticals through the PBS where these pharmaceuticals minimise or delay the impact of chronic conditions

• a system that is affordable for and accessible to all Australians.

• equity of outcomes from health care: our system should ensure that all population groups share the benefits of the health system in terms of health outcomes.

In addition, COTA believes that outcomes in terms of healthy ageing could be considerably improved by greater attention to, and funding for programs which would integrate acute care with pre and post-acute services and develop common entry processes linked to the primary care and the community support system.

The programs which need to assume a greater role in the health system in a flexible and well-integrated way, include:

• Community care.
  
• Step-down, rehabilitation and convalescent facilities.
  
• Allied health services such as podiatry, psychology.
  
• Public health: health promotion and prevention.
  
• Information and support.
  
• Development of strong consumer rights and complaints mechanisms.
  
• Dental health.
  
• Pharmaceuticals.

Community care is often placed into the "welfare" funding basket so is often not taken into consideration at all in discussions about health policy and the financing of the health system. In addition, step-down and convalescent facilities and allied health services are the poor relations in health policy and financing terms and are largely neglected.

Yet COTA is acutely aware of how these low cost services lessen the usage of the mainstream health system.

COTA's preference would be to have these activities much more centrally located in the health system.

Some examples:

• The findings of a study by the Social Policy Research Centre (Turvey and Fine, 1996, p69) suggest that even a small amount of household support has positive effects on mortality rates and the rates of hospital usage for frail older people.

• A good step-down or convalescent facility after a spell in an acute hospital would reduce the incidence of re-admission and complications.

• Health promotion and preventative activities such as breast cancer screening directly reduce the need for expensive medical interventions.

• For many older people, there are no alternatives but to go to a GP and get a prescription for ailments when a treatment in an allied health service, such as physiotherapy, may be more effective over the long term.

Community care

We believe services provided through the Home and Community Care program (HACC) and Community Aged Care Packages (CACPs) and the Coordinated Care Trials play an increasingly critical role in health maintenance of an ageing population. Community care represents an important complementary system to the health system.

A timely, adequate and appropriate level of community care can mean that a frail, older person or couple can continue to live at home for longer periods. This can mean less reliance on health services and residential care.

COTA has had particular concerns about the lack of availability of low levels of support for many older people across the country. We continuously observe problems for older people in obtaining household support, gardening and home maintenance and home renovations.

The people we are concerned about are quite capable of self care and independent living in the community but have difficulty with maintaining a home and garden due to frailty or a low level of disability.

We believe that many older people have their living standards and health compromised because of lack of basic support services. The result can be premature admission to residential aged care or at worst hospital admission or death.

The other major problem in community care which we are concerned about is the cost-shifting between hospitals and HACC.

In some States the pressures on HACC are associated with increased rates of early discharge from hospitals caused by case-mix and cuts to hospital funding. Reform and cost-cutting in hospitals has placed more pressure on the HACC program, eroding its capacity to provide adequate preventive services for low level users.

Clearly, Commonwealth funded community care through HACC and CACPs is experiencing pressures due to a wide range of problems elsewhere in the health and aged care systems. These problems are often linked to the constant tensions between the States and the Commonwealth in terms of financing and roles.

Step-down and convalescent facilities

COTA believes that convalescent facilities or step-down facilities need to be much more developed in Australia. The paucity of convalescent facilities has a number of undesirable consequences:

• premature discharge from hospital back into the community

• excessive pressure on community care services, which means that they are unable to fulfill their primary preventative purposes for people with low care needs.

• higher rates of readmission and relapse to hospital.

Allied health

Medicare does not cover important areas of treatment under the umbrella of allied health services such as physiotherapy, podiatry, chiropractic and psychology. Low income, older people are excluded from these services if they do not have private health insurance. However, insurance may not offer a large enough rebate to make them affordable, especially for people paying health insurance out of a full Age Pension. Older people may gain more benefit from allied health services than from pharmaceuticals. These are often prescribed because other, more appropriate treatments are not affordable or accessible. However, the use of pharmaceuticals as the only form of treatment is a false economy if underlying conditions are not treated and lead to further deterioration which then need more expensive and radical treatments. (It needs to be recognised that pharmaceuticals do have an important role in delaying or minising the effects of certain conditions however).

COTA is also concerned about the poor access to allied health services in rural and regional Australia.

Public health: health promotion and prevention of ill-health

Public health measures play an important role in promoting many aspects of health status for older people. Older people constitute a population group that have a particular interest in the appropriate application of public health measures.

The range of public health issues which are of special relevance to older people are very wide and include:-

diabetes
food and nutrition
injury prevention
violence
suicide
mental health
pharmaceuticals
health promotion
men's health
breast and bowel cancer screening
neurodegenerative disorders
cancer
cardiovascular disease
osteoporosis
physical activity
chronic disorders
palliative care
housing
environmental health services

Public action in all of these areas makes a substantial contribution to the quality of life of older people in terms of the following:

• prevention of health problems;
• appropriate treatment of health problems; and
• support for carers and people affected by health problems.

The great strength of public health is in its focus on prevention and early identification of health problems which is particularly crucial in the case of older people. For example, good nutrition and exercise is a much more cost effective way of dealing with osteoporosis rather than expensive hip replacement and subsequent rehabilitation. There are also examples of imbalances between treatment and prevention such as free treatment for an individual under Medicare for a disease but a cost for a vaccination (as is the case for hepatitis or pneumonia).

COTA is of the view that prevention and health promotion plays a vital part in cost control in the health system. We believe that many common health conditions of older people are preventable and their prevention would mean huge savings to the public purse.

Dental care

COTA considers that good dental health is one of the foundations for healthy ageing.

There are three aspects of the importance of good dental care we wish to highlight.

1. Good nutrition

Good dental health, meaning well-maintained natural teeth or well functioning dentures, is a basic pre-requisite of good nutrition which is a building block for good health. Well maintained natural teeth are always preferable to dentures. Modern dental treatment emphasises maintenance of natural teeth where at all possible.

Poorly maintained natural teeth or poorly functioning dentures constrain the dietary choices of older people. Poor diet is linked to a wide range of conditions in older people such as cardio-vascular disease and bone-thinning. In older people poor diet can contribute to memory loss and poor cognitive functioning. These conditions cause suffering for the individual, their families and carers. These conditions will be more expensive to treat in the long term than some adequate dental care in the short term.

2. Freedom from pain and discomfort

Lack of dental treatment causes physical pain and suffering. This can lead to depression and other mental health problems. It can mean the long term use of pain killers and anti-depressants that have negative effects on overall health and well-being.

COTA argues that poor dental health can contribute to the deterioration in the overall health of older people that can lead to premature admission to a nursing home or death.

3. Social functioning and independence

Good dental health has important implications for adequate social functioning and the independence of older people. Older people can feel constrained in socialising if poor teeth or dentures compromise appearance, speech or eating. We believe that good dental care has a vital role in contributing to the quality of life of older people.

Early intervention for dental problems is important in preventing further deterioration and to encourage preventive dental health practices such as regular and appropriate cleaning.

Many of the older generation have dental health problems as a result of a number of factors:

• the ageing process which results in the wearing down of teeth, fillings and gums
  
• the loss of most or all natural teeth (edentulism) necessitating dentures due to past dental care practices - this is quite common in people over 65
  
• heavily filled teeth which require ongoing maintenance and replacement from time to time

COTA considers that there will be ongoing need for public dental health services that ensure that low income people receive a minimal standard of dental health care. COTA does not envisage that there will be any diminution in need for many years into the future. Older people - people over 55 - will make up a very significant proportion of those requiring public dental health services.

Many people will be reaching older age groups with their own teeth rather than dentures and this will have significant implications in the future for the need for good dentistry to maintain those teeth in good working order. This is especially the case if the teeth have been filled as they are most likely to be for the pre-fluoridisation generation (AIHW, 1994, p97)

A national dental health policy is needed. To achieve the aims of the policy, the Commonwealth will need to provide funding for dental care in addition to that already provided by the States and Territories. The national policy must set standards which:

• Focus on preventive dental services including: regular check-ups, fillings and restoration rather than extractions.

• Ensure that treatment is appropriate and timely: swift, remedial action when problems do arise that aim to save teeth rather than extract them;

• Ensure that dentures are well-fitting and comfortable;

• Enable the public dental service to contract private dentists or services;

• Ensure that people in rural and remote areas have access to public dental services;

• Ensure that people in institutions including residential aged care have access to dental services when they need them;

• Provide services for special needs groups:
  - people on low incomes
  - older, frail people
  - people with dementia
  - people in rural and remote areas
  - people in residential aged care

Pharmaceuticals

COTA believes that the Government needs to balance the growth in outlays under the Pharmaceuticals Benefits Scheme against therapeutic outcomes. Any policy which aims to reduce the access of sick people to the medicines they need is inappropriate.

COTA believes that much more can be achieved through the education of consumers and the medical profession. Education is an important mechanism for restraining growth in expenditure on PBS. As McCallum and Geiselhart (1996, p59) point out,

Drug companies are major funders of all aspects of the medical industry...Consumers need to be as aware of this as they are to tobacco advertising. The polypharmacy problem is a structural issue that can be addressed immediately by controlling pharmaceutical advertising and doctor training. Older people's behaviour is a secondary issue.

Doctors, consumers and pharmacists need better education on drugs which allow them to independently evaluate drug effects and uses.

COTA is concerned about those older people on low incomes who have been affected by the policy changes in recent years such as the removal of some medicines from PBS and the Therapeutic Groups Premium policy. For people reliant on the full Age Pension with no or little additional private income, increased costs for medicines as a result of these changes represents significant hardship. We suggest that this is a major area that the Government must address through supplementary assistance to this group.

COTA is receiving reports of some people in residential care not being able to afford their pharmaceuticals. This is a result of a poor interaction of the co-payment system in residential care and the co-payments through the Pharmaceutical Benefits Scheme.

COTA has particular concerns regarding the inappropriate use of medicines and the rapid growth in use of pharmaceuticals as a substitute for other forms of treatment amongst older people specifically. These factors, we believe, have contributed to the growth in outlays for the Pharmaceutical Benefits Scheme.

Our work with older people, and with the Consumers' Health Forum in its pharmaceutical project of August 1995, identified the need for:

• more information and education about prescribed medicines for older people;

• better communication between consumers and health professionals about the wise use of medicines;

• strategies to encourage older people to manage their own medicines and improve the quality of consumer decisions about the wise use of medicines.

In 1996 the Council on the Ageing ran a highly successful national project for the Commonwealth, the Peer Education Project, which involved the training of older people to speak to groups of older people about the use of pharmaceuticals. We believe there is an ongoing need for the education of older people about pharmaceuticals. We are running the program again in 2000 with the assistance of the Commonwealth Government and the Pharmacy Guild.

Information and support, development of strong consumer rights and complaints mechanisms.

COTA believes that there is a serious problem in the provision of information and support to older people in the health system which can have long term impacts on health. Clear and simple information is important and can often be successfully imparted in community groups.

It is important that consumer rights and complaints mechanisms are part of the health system and are adequately funded.

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PART TWO:

A NATIONAL STRATEGY FOR HEALTHY AGEING IN ABORIGINAL COMMUNITIES

COTA is most concerned about the reduced life expectancy and poor health status of Aboriginal people. According to the Australian Institute of Health and Welfare (AIHW, 1998, p28), life expectancies in 1992-94 for Aboriginal and Torres Strait Islander men and women (living in Western Australia, Northern Territory and South Australia) were 14 to 20 years below those of other Australians.

The AIHW points to the many diseases to which Aboriginal people fall victim, resulting in premature death or disability. These diseases are in the main preventable.

Clearly the factors that contribute to the poor health and reduced life expectancy of older Aboriginal people are very complex and there are many experts in this area who can be consulted by Government.

However, a report to the Council on the Ageing (April 1996) from Heather Campbell and Patricia Dare, Aboriginal health workers of the Tangentyere Council, gives us much insight into the issues confronting older Aboriginal people and their communities. The following are excerpts from their report:

In our work we see that there are some disturbing emerging trends. We see some illnesses in great abundance. For this paper we will take one disease as an example. It is an indication of the health status of ageing Aboriginal people in the Northern Territory.

We are overcome by clients with end stage kidney disease and who are now on a kidney dialysis program. We are now serving the needs of over 20 clients with kidney disease. Remembering that there are approximately 1200 people living on the Town Camps, these numbers indicate a very high incidence of this terrible disease. As you are no doubt aware being on the dialysis program means that the patient must attend the dialysis clinic frequently, (some patients must go three times a week) for a lengthy and tiring procedure.

In the Northern Territory.....Aborigines comprise 22.5 per cent of the total population. Yet Aborigines accounted for 83 per cent of deaths and 68 per cent of hospitalisations for this disease...

There are a number of comments we want to make about renal disease. These comments reflect upon the situation Aboriginal people find themselves in today in a country where medical intervention has ensured an increasing length of life for almost all citizens and an improving quality of life throughout all stages of life. The fact that this is not the case for Aborigines is an example of the inequitable distribution of the resources of this nation at this time in its history. It is an issue of social justice....

What are we suggesting? Well basically there are two Australias being represented at this conference. There is the ageing All-Australian population and there is the sick Aboriginal population. We are not ageing (certainly not gracefully) we are dying. We are dying of sicknesses that are almost unheard of now in the all-Australian population. And we have many fewer opportunities to help ourselves out of the situation we find ourselves in.

Look at it another way. We receive all the publications other services receive about the Ageing in Australia including one on Alzheimer's disease. Well, in our work at Tangentyere we have never had to deal with anyone with Alzheimer's (as far as we can tell). Why not? Well it seems because Alzheimer's is a disease of the very old and we Aborigines don't get very old. We die before we get old. In other words the service community working with the all-Australian population has different problems to deal with from ourselves....

Let's progress to investigate the sort of Ageing that is sought after by all people today. I guess it would be accurate to suggest that we all want to grow old with dignity. We want to minimise pain as far as possible to be able to enjoy the fruits of a productive earlier life by relaxing a little and enjoying the exploits of our children and grandchildren as we age. We don't want to grow old in order to vegetate. We aspire to a satisfying quality of life for many years after retirement. We want to be active, alert, involved in the life of our community. As Aboriginal people we place great weight on the contribution of the elders to our communal life. We respect our elders and rely on their wisdom and guidance.

Having failed kidneys is certainly not a recipe for pain free, enjoyable retirement.

Renal failure, it is pointed out in the paper, is associated with low socio-economic status and poor housing conditions. The conditions for renal failure in later life are set up in children when scabies become infected with streptococcus bacteria:

The existence of scabies and the persistence of the streptococcus bacteria are functions of poor environmental conditions. The difficulty is that we are housing Aboriginal people in inferior and overcrowded houses throughout Central Australia. For example at Tangentyere we have 180 houses for 1200 people plus possibly another 500 semi-permanent visitors. This gives an occupational density of about 7 per household. In the rest of Alice Springs (the non-Aboriginal part of town) the density is about 4.5 persons per household.

As well we have houses that are now ageing and hard to maintain. So we have an ageing, poorly maintained and overcrowded housing stock. Into this situation we place Aboriginal residents who have a short history only of living in permanent, closely settled environments and who lack the cultural history and experience to manage under these difficult and stressful circumstances. To handle this our Old Peoples Service is also a Homemakers Service (we call it HOPs) because we recognise that we can't deal with the problems of the aged and disabled until we can modify the householding skills of the residents of our unsatisfactory houses.

It is apparent from the analysis presented by Heather Campbell and Pat Dare that any improvement in the health status and life expectancy of Aboriginal Australians will only be achieved by an integrated, multi-dimensional approach that incorporates a recognition of the cultural values and underpinnings of Aboriginal people themselves.

At a minimum, Aboriginal communities need the following to improve the life expectancy and health status of members:

• adequate, culturally appropriate housing;

• good nutrition;

• clean water supply;

• access to educational opportunities particularly for children and young people;

• adequate income;

• access to good quality and culturally appropriate health and community services.

We note that Aboriginal people themselves place a high priority on land rights as the basis for any improvement in the basic circumstances in which they live. Without land rights, they argue, Aboriginal people will never have sufficient confidence and self-esteem to move beyond the depressed conditions they currently find themselves in.

COTA is concerned that so few Aboriginal people get to reap the benefits bestowed on other older Australians:

• an age pension, health and community services and various other amenities;

• the enjoyment of reasonable health and facilities to support frailty and ill-health in old age;

• the opportunity to engage in the life of the community and to be part of a family watching children and grandchildren develop.

We believe that urgent action is needed to help more Aboriginal people attain healthy ageing.

Aboriginal people need their elders to facilitate the process by which the social, cultural and economic conditions of Aboriginal communities can be ameliorated.

It is clear to COTA that the national Strategy for an Ageing Australia must incorporate a strand which focuses on helping Aboriginal people achieve healthy, older ages.

The national Strategy for an Ageing Australia needs to include a Strategy for Ageing in Aboriginal Communities which focusses on the particular needs and issues in Aboriginal communities which are contributing to premature deaths and ill health.

Services for older Aboriginal people

While a Strategy for Ageing in Aboriginal Communities must take a broad multi-faceted approach to the task of improving life expectancy and health status of Aboriginal people, there also needs to be immediate improvements to the services that are available for older Aboriginal Australians.

COTA holds a strong view that service arrangements should reflect the known health needs and deficits of the older Aboriginal people. Primary health care services and public health programs should be located wherever possible within or close to Aboriginal communities. Opportunities for participation by members of Aboriginal communities in service planning should ensure that services are culturally appropriate.

Aboriginal health workers should have an important role in the care of older Aboriginal people. There needs to be an expansion of training opportunities in this area.

At the same time, it is important that older Aboriginal people have access to appropriate residential aged care facilities. Facilities such as the Aboriginal Community Elders Services in Melbourne need to be supported and their availability expanded.

Geographically accessible and culturally appropriate health services, community services and residential aged care for older Aboriginal people need to be expanded.

An effective national policy on Aboriginal health must also ensure access of Aboriginal communities to the mainstream services that are available to other Australians. The reality is that many Aboriginal people need to use mainstream services and indeed do use mainstream services where they are available.

However, accessibility to services and successful use of services can be impeded where there is lack of cultural awareness and understanding.

Any strategy for improving Aboriginal health and life expectancy must be underpinned by mainstream services with staff trained for working with Aboriginal people or with trained Aboriginal people themselves.

Aboriginal health policy needs to incorporate both specific services run for and by Aboriginal people and mainstream services which are culturally sensitive and provide appropriate services for Aboriginal people.

Aboriginal communities need to have access to mainstream services which are staffed by people who have the cultural awareness skills to ensure that Aboriginal people are able to successfully use the services.

References

Australian Institute of Health and Welfare (1998) Australia's Health, Canberra, AGPS

Australian Institute of Health and Welfare (1994) Australia's Health, Canberra, AGPS

Australian Bureau of Statistics (1999) Retirement and Retirement intentions, November 1997, Catalogue No. 6238.0, Canberra, 1998.

Bishop B (1999) The National Strategy for an Ageing Australia, Healthy Ageing Discussion Paper

Budget Standards Unit (1998) Newsheet No. 4, Social Policy Research Centre, University of New South Wales

Department of Family and Community Services, Submission to House of Representatives Standing Committee on Employment, Education and Workplace Relations: Inquiry into issues specific to workers over 45 years of age seeking employment, or establishing a business, following unemployment, Department of Family and Community Services, 1999.

Hupalo P and K Herden (1999) Health policy and inequality, Department of Health and Aged Care, Canberra

Industry Commission (1993) Public housing, Industry Commission, Canberra, AGPS.

McClelland, A., Pirkis, J., Willcox, S., Enough to make you sick: how income and environment affect health, National Health Strategy, Research Paper No. 1, 1992.

McCallum J and K Geiselhart (1996) Australia's new aged, Sydney, Allen and Unwin.

Podger A (1998) Health policy and its impact on poverty, Paper presented to Centre for Public Policy, University of Melbourne, August 1998

Royal Australian College of Physicians, For richer, for poorer, in sickness and in health: the

Australian Bureau of Statistics (1996) Australian Social Trends, Canberra, AGPS.

Saunders P et al (1998) Development of indicative budget standards, Policy Research Paper, No.74, Social Policy Research Centre, University of New South Wales, Sydney.

Turvey K and M Fine (1996) Community care: the effects of low levels of service use, Social Policy Research Centre, University of New South Wales, Sydney.

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Copyright © 1999 Council on the Ageing. All rights reserved.
Date: Feb 2000
Revised: 30 October 2001

Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent, Melbourne Vic 3004
Tel (03) 9820 2655 Fax (03) 9820 9886
email cota@cota.org.au