World class care: response to National Strategy for an Ageing Australia discussion paper

World class care

COUNCIL ON THE AGEING (AUSTRALIA)

World Class Care

Response to National Strategy for an Ageing Australia Discussion Paper

October 2000

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

INTRODUCTION

One of the largest and most important tasks for the Government as a result of population ageing will be to carefully plan for the health and aged care systems.

There will be a large number of considerations including:

the needs and expectations of the ageing population and the whole community

the financing of the system including the relative contributions of private contributions, health and aged care insurance, co-payments and public financing

the place of high cost medical interventions in the health system

the comparative roles of, and links between, the private and public systems

the links between the various parts of the system

the needs of special groups particularly indigenous Australians.

This response to the World Class Care paper outlines COTA's vision of the health and aged care system. The World Class Care paper presents a great many facts about the health and aged care system that form a useful background to understanding the issues that need to be considered. However, we note that the discussion paper does not give a definition of "world class care" nor does it consider "best practice" models or innovative approaches of care from various parts of the world.

Health and aged care policy is a very complex area. COTA's contribution to the National Strategy in this area is to propose what would constitute a health and aged care system to the highest standards available anywhere in the world. The Government's role is to develop the implementation processes for the principles and strategies.

COTA has developed a twelve point action plan or strategy for achieving world class care.

Strategy 1: Maintaining and strengthening universal services as the foundation for equitable outcomes in population health accompanied by high levels of effectiveness and efficiency in the health system.

Strategy 2: Fostering strong integration between all parts of the health and aged care system.

Strategy 3: Ensuring that health promotion and prevention of ill-health are adequately funded as the basis for high levels of population health.

Strategy 4: Promotion of the sound use of pharmaceuticals amongst older people.

Strategy 5: Developing specific targeted health strategies for indigenous Australians which also incorporate a strategy for improved access to mainstream health services.

Strategy 6: Improving access to allied health services to ensure that people have access to the most appropriate forms of treatment for their condition.

Strategy 7: Implementing and funding a national dental health strategy.

Strategy 8: Developing a mental health strategy for older Australians

Strategy 9: Enhancing home and community care services as a means of preventing admission to hospitals and residential care and meeting the expectations of older Australians to remain at home as long as possible.

Strategy 10: Strengthening discharge planning, post-acute, rehabilitation and palliative facilities to ensure the maximum effectiveness of treatments in the acute sector.

Strategy 11: Developing a residential care system that meets the needs and expectations of older Australians

Strategy 12: Supporting carers to the fullest extent.

TWELVE POINT STRATEGY FOR WORLD CLASS CARE

STRATEGY ONE:

MAINTAINING AND STRENGTHENING UNIVERSAL SERVICES AS THE FOUNDATION FOR EQUITABLE OUTCOMES IN POPULATION HEALTH ACCOMPANIED BY HIGH LEVELS OF EFFECTIVENESS AND EFFICIENCY IN THE HEALTH SYSTEM.

COTA begins this section with the following statement from the recently released World Health Report 2000 of the World Health Organisation:

The ultimate responsibility for the overall performance of a country's health system lies with government, which in turn should involve all sectors of society in its stewardship.

The careful and responsible management of the well-being of the population is the very essence of good government. For every country it means establishing the best and fairest health system possible with available resources. The health of the people is always a national priority: government responsibility for it is continuous and permanent. Ministries of health must therefore take on large part of the stewardship of health systems.

Health policy and strategies need to cover the private provision of services and private financing as well as state funding and activities. (WHO, 2000, p 4)

COTA concurs with this view that more than in any other element of a national economic system, the provision of health services and the allocation of health related resources requires intensive and extensive government resourcing, policy direction and program administration.

The Council on the Ageing has long held the view that a universal health system has immense advantages in both equity and efficiency terms. 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 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 to ensure taxpayers get the best deal in health services because it is a single major purchaser – thus it is a price giver rather than price taker.

The Government has made a substantial financial commitment to boost the private health insurance sector through a 30 per cent rebate on premiums. COTA opposed this measure because it reduces resources that could be available to the public system and because there is no evidence that it constitutes an efficient and effective use of resources.

In contrast, COTA supports Lifetime Health Cover as it is a sound, structural way of encouraging those who can afford it to take up private health insurance. In addition, Lifetime Health Cover does not impose any budgetary pressure.

COTA believes that the Government's drive to bolster private health insurance may result in a two-tiered health system in Australia based on socio-economic status. There is a risk that over time high and middle income earners will want to opt-out of the public system and will refuse to subsidise the public system through general taxation and the Medicare levy (see for example the views of John Deeble, the architect of Medibank, Australian Financial Review, 11 October 2000, p40).

Lower income earners, including many older people, may be relegated to an increasingly under-resourced and residual public system.

COTA considers that the public system should deliver high quality, free and accessible health care. This system provides the best health outcomes for the population and is able to keep costs down.

We believe that older people should have confidence in this system and should not feel forced to take on private health insurance because they are concerned that they will not receive adequate treatment through the public system. Private health insurance should be an optional extra for older people if they want it and can afford it. It should not be seen as a requirement for people on low incomes who should have guaranteed access to all forms of treatment through the public system.

COTA is concerned that older people's demand for private health insurance is currently driven by a range of negative factors. We have found through our own membership that many older people struggle to maintain private health insurance for the following reasons:

fear of long waiting periods for non-urgent types of surgery such as hip replacements

fear of not receiving treatment for potentially life-threatening but non-acute conditions such as severe angina

fear of ill-treatment in a public hospital in the event of an emergency such as being left for hours on a trolley in a corridor

the perception that ongoing cost cutting in the public hospital system has seriously undermined the quality of care in that system; and

the perception that it is better to over-insure than take risks in gaining access to health care.

In addition some older people believe that private health insurance will give them greater control and comfort if hospitalised such as choice of doctor and a private room.

As a result of these factors many older people whose main source of income is the Age Pension are paying for private health insurance premiums they can ill-afford. Premiums can present 15 per cent of a pensioner's total income.

It will be essential that Australia's public health system continues to operate as a world class system providing an optimal service for all citizens. It will do this by continuing to be a universal system.

Long term objectives for the health system

The OECD (1994) identified a number of desirable objectives for national health systems. These provide a useful basis for the future planning of Australia's system.

1. Adequacy and accessibility of health care: a minimum core of health services available for all citizens, with treatments available according to need.

COTA believes that Australia meets this criterion reasonably well under the present system but that it should be continuously strengthened. It is possible that increasing privatisation will undermine this objective.

We are concerned about the continuing reports of significant failures within the public hospital system and we believe there is inadequate attention paid to allied health and community care. COTA believes that under the current health system health promotion and prevention are inadequately resourced and are not given the priority needed to improve the health outcomes of the older population.

2. Equity of outcomes from health care: a system should ensure that all population groups share the benefits of the health system in terms of health outcomes.

Australia does have reasonably equitable outcomes from its health system with the major exception of indigenous health. COTA recommends that indigenous health is the basis for a specific strategy as outlined below.

In addition, the AIHW (1998) points to the poorer health status of people in rural and remote areas. Australia has very low coverage of general practitioners in rural and remote areas. Public hospitals have progressively been cut back in rural areas. It is essential that the health system in rural and remote areas is rebuilt and maintained to ensure that people living in these areas have access to as high a standard health care as people living in urban areas.

3. Income protection for the individual.

A good health system needs to provide health services that will not impoverish users of the system. Australia's health system is reasonably effective in protecting individual incomes. As a univeral health insurance system, financed principally through taxation, the risk of sickness and the need to use expensive health services is shared across the community.

We have reason to greatly fear the Americanisation of Australia's health system which would mean that a substantial proportion of the population, the most disadvantaged, would have greatly reduced access to high quality services.

4. Macro-economic efficiency: the proportion of GDP absorbed by health expenditures.

Australia's system measures up well on this score at around 8 per cent of GDP or the average for the OECD over the last decade. COTA is concerned that greater privatisation of the health system would push up this level of expenditure without achieving any improvements in health outcomes but increased profits of private entrepreneurs.

Private hospital treatment is more expensive than public hospital treatment. Public hospitals are more efficient and effective than private hospitals. They have lower costs because they are under greater financial pressure than private hospitals. Privately insured patients receive more procedures than public patients.

The Australian Institute of Health and Welfare reported in the Health Expenditure Bulletin (November, 1998) that private hospitals were a fast growing area of health expenditure between 1989-90 to 1995-96 at 8.4 per cent per year compared to 2 per cent per year for public acute care hospitals.

5. Micro-economic efficiency: the extent to which the system operates efficiently and effectively, offering value for money, consumer satisfaction etc.

The extent to which Australia's health system operates as efficiently and effectively as it can, is a matter of dispute in a number of areas. However, in recent years a number of sensible measures have been introduced which make the system both more efficient and effective at the micro-economic level.

Of particular note are the initiatives in Enhanced Primary Care including health assessments for people aged 70 and over and case conferencing which are having an important role in moving Australia's health system to greater efficiency and effectiveness. There is an ongoing need for such measures of continuous improvement in Australia's health system. The Coordinated Care Trials are also an important initiative in terms of achieving greater micro-economic efficiency.

6. Consumer choice

Consumers in Australia have choice of doctor they attend in general practice but no choice if they are admitted as a public patient in a public hospital. For some people, this is a major issue and those that can afford to (and some who can't) choose to take out private health insurance for this reason. Choosing a specialist is largely a myth as choice is usually made by the general practitioner.

In the broad perspective, choice of doctor has not proved a major issue for most people. Many public patients receive treatment from first rate doctors and specialists. All Australian doctors are trained to world class standards and there are stringent registration requirements for foreign doctors.

Consumer choice must be accompanied by consumer education if it is to have genuine meaning in the health system. Consumer education must cover the full range of services, entitlements and rights in the health system. Consumer education will have an important bearing on maintaining the efficiency and effectiveness of the health system.

A strong complaints mechanism is also necessary for an effective consumer role in the health system.

7. Provider autonomy

In Australia, medical practitioners form a group of powerful, well-educated and well-resourced professionals preferring to make their own decisions about how they work and how much their work is worth.

It is not in the best interest of the community, however, that they should be allowed to operate from a totally self-regulating position. Medicare has been most effective in placing some caps on doctors' fees and hence has succeeded in controlling the cost of the health system. There is no reason for any change in the current balance between self-regulation and the disciplines on the sector provided by the Medicare system.

Cost escalation is apparent in the specialities where there are shortages and these medical practitioners can demand high fees in addition to Medicare rebates. There is a need for research to determine the number of specialists needed in the future.

STRATEGY TWO:

FOSTERING STRONG INTEGRATION BETWEEN ALL PARTS OF THE HEALTH AND AGED CARE SYSTEM.

A critical element of a successful health system is strong integration between all parts to achieve the maximum levels of efficiency and effectiveness.

To a significant extent the Coordinated Care Trials are attempting such integration and it will be important for these to be further developed and refined for general application across the health system.

It is also important that there is a high level of coordination between the health and aged care systems as well between parts of each system.

STRATEGY THREE:

ENSURING THAT HEALTH PROMOTION AND PREVENTION OF ILL-HEALTH ARE ADEQUATELY FUNDED AS THE BASIS FOR HIGH LEVELS OF POPULATION 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.

More than any other age group, the population of older persons represents tremendous diversity in their physiological, social, psychological and economic characteristics. While only a minority fulfils the stereotype of the ill, confused and isolated aged, many are active, healthy and independent. This diversity is extremely important to the discussion of preventive health strategies for this population.

Health promotion for older people is not simply about the absence of disease and the avoidance of premature death. It is about supporting older people to stay independent and maintain active and fulfilling lives despite the possible presence of illness. Health promotion aims to create long term changes, not only in the structures and environments which can improve the social, psychological, physical health and quality of life of older people, but also in community attitudes about our older population.

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

- chronic illness
- mental health, suicide and depression
- male specific health issues
- female specific health issues
- cancer screening
- neurodegenerative disorders
- cardiovascular disease
- dementia
- injury
- medication control.

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)

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.

Health promotion should be funded to a fixed proportion of overall expenditure in the health system.

STRATEGY FOUR:

PROMOTION OF THE SOUND USE OF PHARMACEUTICALS AMONGST OLDER PEOPLE

Management of the costs of and access to pharmaceuticals will be a critical part of achieving a world class health and aged care system.

Present and future governments will need 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. Pharmaceuticals are a method of treatment under the terms of evidence-based medicine.

Planning for the future must particularly take account of the needs of low income people many of whom will be elderly and with chronic conditions. It will be essential that pharmaceuticals remain accessible and affordable for these groups.

However, COTA believes that 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.

The Council on the Ageing 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 has 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 and 2000 the Council on the Ageing has run a highly successful national project with Commonwealth funding on the Wise Use of Medicines 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 using a range of appropriate methods.

STRATEGY FIVE:

DEVELOPING SPECIFIC TARGETED HEALTH STRATEGIES FOR INDIGENOUS AUSTRALIANS WHICH ALSO INCORPORATE A STRATEGY FOR IMPROVED ACCESS TO MAINSTREAM HEALTH SERVICES.

According to the Australian Institute of Health and Welfare (AIHW, 1998, p28), life expectancies for Aboriginal and Torres Strait Islander men and women (living in Western Australia, Northern Territory and South Australia) are 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.

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.

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.

Service arrangements should reflect the known health needs and deficits of 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.

STRATEGY SIX:

IMPROVING ACCESS TO ALLIED HEALTH SERVICES TO ENSURE THAT PEOPLE HAVE ACCESS TO THE MOST APPROPRIATE FORMS OF TREATMENT FOR THEIR CONDITION.

Medicare does not cover many 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).

It is vital that those allied health services which are subsidised, especially hearing and optical, continue to meet the needs of the ageing population.

The Co-ordinated Care Trials may in the future offer more options for older people to gain access to allied health services.

Access to allied health services needs to particularly to be strengthened in rural and remote areas.

STRATEGY SEVEN:

IMPLEMENTING AND FUNDING A NATIONAL DENTAL HEALTH STRATEGY.

COTA considers that dental health should be an essential component of a health and aged care system of world class standards. It is an intrinsic element of primary health care as pointed out in the discussion paper (p14). The greatest deficiency of our national health system is that there is no assistance for people to maintain oral health. One of the worst examples of poor public policy is in divorcing the oral health of individuals from all other aspects of their health care.

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

STRATEGY EIGHT:

DEVELOPING A MENTAL HEALTH STRATEGY FOR OLDER AUSTRALIANS

Many older people suffer from depression and mental illness. Very often the conditions are undiagnosed or incorrectly attributed to old age or dementia. Hence older people are recorded as having the lowest levels of mental illness (AIHW, 2000, p 77)

In addition, depression is very often linked to other diseases associated with old age.

Older people have not been a group that have been targetted for mental health policies in the past.

COTA advocates for a strategy that seeks to ensure that older people are correctly diagnosed for mental illness, particularly depression and are offered high quality treatment.

STRATEGY NINE:

ENHANCING HOME AND COMMUNITY CARE SERVICES AS A MEANS OF PREVENTING ADMISSION TO HOSPITALS AND RESIDENTIAL CARE AND MEETING THE EXPECTATIONS OF OLDER AUSTRALIANS TO REMAIN AT HOME AS LONG AS POSSIBLE.

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.

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.

The recent report Targeting in the Home and Community Care Program (National Ageing Research Institute and Bundoora Extended Care Centre, 1999) shows that there needs to be a fundamental reconsideration of how resources within the HACC program are distributed between competing priorities between various levels of care needs.

COTA supports the three tier structure proposed in the report:

Tier 1: Basic HACC – this level to be characterised by broad eligibility and open access.

Tier 2: HACC "Plus" – at a certain level of service use or identified need, clients would be referred to a Comprehensive Assessment Services. All additional services to be funded through brokerage funds. It is estimated that 15 per cent of clients would be eligible for HACC plus.

Tier 3: HACC "Exceptional Clients" – high need clients identified through the Comprehensive Assessment Services. This group would be funded through a pool of funds allocated on a case by case basis rather than HACC funds. It is estimated that 2 per cent of clients would be in the "exceptional" group.

COTA considers that this model would substantially assist in ensuring fair allocation of resources between the varying levels of demand for services between low, medium and high need clients.

STRATEGY TEN:

STRENGTHENING DISCHARGE PLANNING, POST-ACUTE, REHABILITATION AND PALLIATIVE FACILITIES TO ENSURE THE MAXIMUM EFFECTIVENESS OF TREATMENTS IN THE ACUTE SECTOR.

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.

The availability of timely and appropriate rehabilitation for older people is essential to maintaining function and quality of life. Levels of functioning in areas such as mobility, continence, hearing and vision for example can be maintained and deterioration in function significantly reduced through early intervention and health promotion strategies.

In addition, Australia needs to strengthen its palliative care facilities to ensure that the end of life is as positive and humane experience as it can be.

A world class health and aged care system does not only relate to acute hospital services and aged care but also to supporting services in discharge, post-acute, rehabilitation and palliative care.

STRATEGY ELEVEN:

DEVELOPING A RESIDENTIAL CARE SYSTEM THAT MEETS THE NEEDS AND EXPECTATIONS OF OLDER AUSTRALIANS

Australia's residential care system must continuously adapt to the changing demography and the needs and expectations of older people and their families.

COTA welcomed the Government's leadership in providing resources for the restructuring of residential aged care. This initiative needs to be maintained and extended. Residents need a viable and sustainable industry which is able to deliver quality care. To achieve restructuring, new approaches will be needed and some of the current policies will need amending.

There have been some important recent improvements in residential aged care in the areas of quality assurance, complaints mechanisms and prudential arrangements.

Major issues remain as to the long term future of the industry and the options for its development.

There is a need for some definitive information about consumer requirements and expectations of residential aged care accommodation and services. Research on older people's expectations of aged care facilities is needed. This research is imperative at a time when aged care services are expected to rebuild or build new facilities.

The interface between community care and residential care needs to be carefully assessed with a view to achieving the right balance. Many people who go into residential care would prefer to stay in their own home but there are insufficient community services.

In addition, there are practical, ongoing issues of concern in the following areas:

Capital funding for residential aged care: it is not clear what the long term capital requirements are. Further research is needed.

Additional income tested fees which are returned to the Government: the fees do not add to the pool of funds for residential care but offset the costs to the Government. COTA argues that co-payments and fees should only be used to augment the funding base.

The up-front payment of accommodation bonds for residential care: an ongoing issue is that people going into low care residential services are required to pay the bond immediately necessitating the sale of the family home. COTA believes it would be more humane and just to allow a six month deferral of payment until the future of the person is properly assessed.

The residual assets limit of two and half times the annual single Age Pension: COTA believes that this is inadequate protection for older people. They need to be able to reserve more of their savings and assets when going into residential care.

Issues surrounding dementia care: residential care needs to develop more sophisticated facilities for people with dementia.

Respite care: there is an ongoing shortage of respite places for older people in the community living with carers.

Consumer information and consumer rights

Older people and their carers need access to information regarding residential care through a multitude of distribution points, e.g. libraries, older people's organisations, etc. A website directory is the best way to achieve ready access to up-to-date aged care service information.

Council on the Ageing (Australia) and the Seniors Information Service (SIS) of South Australia have prepared a proposal to develop a National Website Directory of Aged Care Services.

A National Directory mounted on a website will provide older people and their carers with up to date information on residential facilities. The Seniors Information Service has already undertaken preparatory work which would form a base for this project.

The first phase of the project would produce a model data base, the design of the website and the cooperation of each State and Territory Seniors Information Service. The second phase would be the implementation of the National Directory. The third phase would be the maintenance and ongoing functioning of the National Information Service.

Consumer information is fundamental to the development of a strong culture of consumer rights in residential aged care.

Complaints mechanisms

A critical aspect of a healthy aged care system is a strong complaints mechanism. The mechanism needs to ensure the confidentiality of persons making complaints and a guarantee of timely action on the issues. Complaints are an important part of any quality management system. The complaints mechanism should be entirely independent.

The handling process needs to guarantee that there is an immediate response to matters that constitute serious breaches of health and safety regulations with the aim to resolve the complaint promptly. Appropriate, specified time-frames need to be established for the treatment of other complaints which although of less immediate seriousness, constitute an ongoing risk to the health and well-being of residents.

Workforce planning

One of the most important elements of developing a world class aged care system will be to ensure that there is an adequate workforce to meet needs in the future.

Employment in aged care services requires sophisticated and ongoing training to ensure staff have the most up-to-date skills and knowledge in the area.

The aged care industry must be prepared to offer conditions and pay salaries that will attract the highest calibre nursing staff and other care workers.

There is an increasing number of high care residents in residential care. Complex, chronic conditions and episodic acute care require skilled responses.

Financing long term care

With the ageing of the population, particularly the growth in the proportion of the population aged over 80, Australia needs to plan to ensure that it will manage the growth in costs for care in the future.

Should private health insurers develop products for long term care?

Do we need some form of social insurance for long term care such as recently introduced in Germany, Singapore and Japan?

Should long term care be primarily funded through general revenue?

What is the relative balance between user contribution and public subsidy for long term care?

It will be essential that any option adopted, ensures equity of access to high quality care for all groups in the community regardless of income or other factor.

STRATEGY TWELVE:

SUPPORTING CARERS

Carers play an essential role in the development and maintenance of a system of world class care.

Although there has been significant improvements in recognition of the role of carers in recent years such as the 1998 Staying at Home package, it must be recognised that carers issues have emerged from a very low base.

In addition, a number of those needing care and their carers have also been affected by increased user charges for health, aged care and community care services in recent years offsetting some of the benefits.

The difficulties that carers face cannot be underestimated. Many are older people who are caring for a loved one. They may have their own health problems to contend with. There may not be a family or community network to support them and they may be at risk of depressive illness.

For younger carers, the caring role may mean that they are unable to work or work full time. This can have very significant long term social and economic implications such as retirement savings.

The caring role, while having its rewards, can involve immense emotional, physical and economic pressures for carers. Caring for a seriously ill or disabled person is a difficult and challenging undertaking.

People who choose this role should be given the maximum level of support available. However, they should also have a choice as to the extent and nature of their caring roles. Appropriate community care, residential care and respite services must be available when needed.

For carers of people with dementia, there are special support needs. Alzheimer's disease can develop over a very long period of time and there are different phases of the disease. The carer will have evolving support needs over this time.

There are a number of priorities for the ongoing support of carers.

Respite care

Respite is of paramount importance to carers. Carers need a range of options which provide them with regular breaks from the demands of caring.

People with dementia or sensory loss may be unable to use residential or centre based respite. For this group in-home respite must be available.

While a person is receiving respite care, the carer is still paying accommodation costs. During respite the person in care pays 85 per cent of the Age Pension to the nursing home and 85 per cent of the Age Pension to the hostel. Families of older people can be faced with a double financial burden if they have to pay for a respite bed and also their normal accommodation costs.

It is essential that there is adequate funding for, and access to, respite. In addition, the nature of respite services are constantly adapting to the changing needs and circumstances of carers and the people they are caring for.

Community care

It is essential that carers are supported by adequate services provided through HACC. The strains of the caring role can be substantially eased by home help and other services to the frail elderly or disabled person being cared for.

Training of carers of people with Alzheimer's disease

Alzheimer's disease is a complex condition requiring specialised training of carers for the benefit of both the person and the carer. In addition, there is emerging evidence that there is a range of innovative, ameliorative measures that can be employed for people with Alzheimer's disease. However, it is critical that training should not be seen as a substitute for respite and support services for Alzheimer's carers but rather as a facet of an overall package of support. An important point about adequate and appropriate training for

Specifically trained Alzheimer's carers in residential aged care results in improvements to the quality of care of all residents.

CONCLUSION

Australia is well-positioned to develop a system of world class care to meet the needs of the ageing population. However, this objective will require careful long term planning, ongoing research and assessment of risk factors.

It will be critical that the strengths of our present system are not lost in the future.

We must build up a system on the foundations of:

Social equity – this means devising health policies which ensure the equal treatment of all members of the population irrespective of income, social class, location or other factor in relation to their access to world class care.

Allocative efficiency – this means allocating resources in health and aged care to those policies and programs that produces the greatest benefit to the most numbers of people.

Cost effectiveness – this means implementing policies and programs which are effective in improving the health and well-being of the population.

These objectives require careful management of policies in the macro sphere of the health system such as in the areas of resource allocation between public and private systems. They also require attention at the micro sphere such as in ensuring that programs which have measurable benefits to the population are delivered efficiently and effectively.

As we stated at the beginning, the Government is the cornerstone in the stewardship of Australia's health system.

References

Australian Institute of Health and Welfare (2000) Australia's Health, Canberra, Australian Institute of Health and Welfare.

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

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

National Ageing Research Institute and Bundoora Extended Care Centre (1999) Targeting in the Home and Community Care Program, Canberra, Department of Health and Aged Care.

OECD (1994) The Reform of Health Care Systems: A Comparative Analysis of Seven OECD Countries, Paris, OECD.

World Health Organisation (2000) World Health Report 2000 Health Systems: Improving Performance, Geneva, World Health Organisation.

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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