active ageing as part of its agenda to promote social inclusion and reduce social isolation. Helping older people maintain their independence whilst staying connected to the community has been identified as key policy principle. This focus, together with the system developments outlined above, suggest that the community aged care sector will be significantly remodelled in Australia over the next few years.

Carers and the interface between formal and informal care

Formal, publicly funded services represent only a small proportion of total assistance provided to frail older people. Extended family and partners are the largest source of emotional, practical and financial support for older people; more than 90% of older people living in the community in 2003 who required help with self-care, mobility or communication received assistance from informal care networks of family, friends and neighbours (Australian Bureau of Statistics [ABS] 2004). Many people receive assistance from both formal aged care services and informal sources.

Extended family and partners are the largest source of emotional, practical and financial support for older people.

Currently, governments recognise the essential support provided to older people by carers. In Australia, the essential role of informal carers in assisting older people to remain in the community is recognised through the provision of HACC services to carers and services such as the National Respite for Carers Program (NRCP). The NRCP provides community respite services and is funded by the Australian Government. Expenditure on this program was $166.9 million in 2006–07. The NRCP assisted nearly 130 000 people in 2006–07 (Productivity Commission 2008).

The literature on long-term care for the older population has focused on trade-offs among different types of personal care in order to address the ‘woodwork effect’; that is, the concern that public coverage for home care could cause a reduction in informal care (Agree et al 2005). However, studies have generally found that formal home care does not substitute for (or crowd out) informal care and, in many cases, may supplement informal care (Kemper et al 1987; Tennstedt et al 1996). Cohen, Weinrobe and Miller (2000), in a North American study of informal carers, found that whether or not formal care substitutes for informal care is related to the characteristics of the caregiver. For adult children formal care may substitute for informal care, but this is not generally the case for spouses. Where the informal caregiver provides 8 hours per week or less of help with activities of daily living (ADL), paid help also tends to be low, but where the informal caregiver is providing large amounts of ADL help, paid help is also used for large blocks of time. Increasing the provision of community care has been suggested as a measure to encourage workforce participation in women who are currently providing informal care outside of the household (Viitanen 2007).

Informal carers actually facilitate formal care provision. Few older clients, either in Britain or the USA, receive formal care alone (Davey & Patsios 1999). Similarly, our analysis of the ACAP MDS (Howe et al 2006) shows that clients with no carer are less likely to be using services than clients with a carer, and clients with co-resident carers are the group most likely to be using HACC and CACPs.

Much less attention has been paid to where the cultures of the formal and informal sectors clash. A gulf may develop between the ways in which families perceive the task of care-provision for someone who is sick or disabled and the way in which professional carers approach the task (Levine & Murray 2004). This gulf can lead to mutual incomprehension, disagreements and even conflict. At worst, professionals ignore families’ perceptions and preferences, while families fail to comply with health care directions; professional carers perceive well-meaning family carers as interfering, while family carers see professionals as uncaring and unsympathetic, and each views the other as incompetent. This is particularly a problem where formal care is highly medicalised and removed from everyday experience.

A gulf may develop between the ways in which families perceive the task of care provision for someone who is sick or disabled and the way in which professional carers approach the task.

Tensions and pressures

The combined effects of population trends, fiscal pressures and developments in service delivery have increased pressure to ensure that resources available to the community aged care services are used in the most effective manner.

Population

As with many western nations, our dramatically ageing population poses significant challenges for governments (World Health Organization [WHO] 2002). The large baby boom generation is ageing and the number of older people is projected to increase rapidly. As the youngest of the surviving baby boomers reaches 65 years of age in 2031, the population aged 65 years and over is projected to reach 5.4 million (more than double the number in 1999) and will represent 22% of the total population (compared with 12% in 1999). As the youngest baby boomers reach 85 years of age in 2051, importantly, the population aged 85 years and over is projected to reach 1.3 million (more than five times the number in 1999) and to represent 5% of the total population (Trewin 2001).

In spite of steady growth in funding, all providers report that demand for services exceeds their capacity to supply them. Factors such as an increase in the number of clients remaining home with complex care needs; difficulties accessing residential care; shorter hospital stays; more outpatient and day treatments; lack of post-acute home care provision from private hospitals; and higher community awareness and expectations about the benefits of the HACC program have all contributed to rising demand (Wittenburg et al 2004).

In some countries, this increasing demand has resulted in longer waiting lists for clients assessed as having low-level care needs. This is cause for concern, as research has suggested that risk may be imposed on clients if delivery of small amounts of critical services — targeted at clients at the time need is expressed — is delayed, or if services are not available at all (Elkan et al 2001; LaPlante et al 2004). If people with lower level needs are neglected, the opportunity to provide restorative services, at a time when clients are likely to retain sufficient capacity to maximally benefit, may be lost. It should be noted that a person’s ‘need’ for services is related not just to their level of functional dependence, but is also strongly affected by their circumstances, especially the extent to which they have support from their family and community.

A person’s ‘need’ for services is related not just to their level of functional dependence, but is also strongly affected by their circumstances, especially the extent to which they have support from their family and community.

The steadily rising demand for services also continues to place pressure on many traditional community care providers to maintain services, sometimes over many years — for example, the provision of domestic services or meals on wheels — to all eligible clients in the community (Howe et al 2006; Parker 2001; Pilkington 2006). In some countries, this has resulted in longer waiting lists or cessation of service for those clients assessed as having low-level care needs.

In the absence of any further improvements in effectiveness of our health and community care systems, it is unlikely there will be any deceleration in the growing demand for home care services. Rather, systemic issues are likely to have an increasing impact, including ongoing difficulties recruiting and retaining community care staff and the projected decline in family care with an increase in women entering or remaining in the workforce.

New models of ageing and community expectations of community care

Successful ageing

A key concept that has emerged in attempting to rethink how to address the needs and maximise the health and wellbeing of our ageing population is that of ‘successful ageing’ (Browning & Kendig 2003, 2004). Impetus for a conceptual shift towards more active, restorative models of care is mirrored by conceptual developments that have occurred within gerontology about what constitutes successful ageing.

Many traditional approaches to aged care emphasise rest, comfort, assistance and support. It has been suggested that this dependency model shares some features with the outdated ‘disengagement theory’ (Cumming & Henry 1961), popular in gerontological research in the 1960s. This theory proposed that in the normal course of ageing, people gradually withdraw or disengage from social roles as a natural response to lessened capabilities and diminished interest, and disincentives from the broader society to participate. Older people are viewed as happy to retire from work or family life, in order to make room for younger individuals. While winding down and preparing for death, they are then free to pursue other solitary, passive activities.

Recent theories of successful ageing have undergone a major shift in emphasis. The focus is now much more on the promotion of activity and active participation in society in order to maximise the physical and mental wellbeing of people as they age, rather than any suggestion that older adults should disengage from activities or society (Buys & Miller 2006).

The focus is now much more on the promotion of activity and active participation in society in order to maximise physical and mental wellbeing.

Over the previous decade, broad-based ‘theoretical frameworks’ have been developed to articulate specific domains of interest and associated outcome measures (Buys & Miller 2006). A variety of terms have been used to describe these frameworks, including ‘healthy ageing’, ‘productive ageing’ and ‘successful ageing’. Recently, the WHO published an ‘Active Ageing’ framework (WHO 2002), designed to overcome key criticisms and incorporate all the most important aspects of previous frameworks. The term ‘active ageing’ was chosen to emphasise the valuable contribution older people make to their families, communities and society. It is defined as: ‘the process of optimising opportunities for physical, social and mental wellbeing throughout the life course, in order to extend healthy life expectancy, productivity and quality of life in older age’ (WHO 2002: 12). The framework emphasises the value of continued involvement across six life domains: social, economic, civic, cultural, spiritual and physical. The phrase ‘engaged in life’ captures its underlying philosophy.

Conceptually, the WHO definition of active ageing comprises three key pillars:

1. participation: life-long learning, paid and unpaid work

2. health: achieving and maintaining good physical and mental health in later life

3. safety: ensuring the protection, safety and dignity of older people by addressing the social, financial and physical security rights and needs of people as they age.

While the quality of the ageing experience will be determined by all three key pillars, there is some ongoing dispute about their relative importance. The West Australian Active Ageing Taskforce has suggested that participation, not health, should be the central pillar of the model. They also suggested that engagement in social and family connections should be placed under the participation pillar rather than the health pillar (Government of Western Australia 2003). Some recent Australian survey findings on older people’s perceptions of what constitutes successful ageing are consistent with the Western Australian perspective; that participation, including participation in social activities, is central to older adults’ views of what constitutes successful ageing (Buys & Miller 2006).

Community expectations

Both the community and governments have been aware for many years that the provision of community care services results in an overall improvement in the quality of life and maintenance of a basic standard of living for many frail older adults in the community and may reduce or delay high-intensity, high-cost services such as residential care or hospital admission (Elkan et al 2001). Currently, the majority of services are provided in a largely standardised way to all eligible clients, and often act to substitute for activities previously undertaken by the individual prior to them experiencing difficulties with looking after themselves.

A growing number of critics have suggested that community care programs in Australia are not as successful as they could be because they rely on an outdated ‘dependency’ model of service provision rather than a newer focus on activity, independence and successful ageing (Baker et al 2001; Baker 2006; Glendinning et al 2008; Hallberg & Kristensson 2004; Kane 1999; Lewin et al 2006; O’Connell 2006). Current approaches often lack an emphasis on the promotion of healthy lifestyles and daily routines, social support, exercise, and autonomy and control, despite strong evidence that these are strongly linked to the maintenance of health and independence in older adults (Peel et al 2004; Seeman & Crimmins 2001; Stuck et al 1999).

Most approaches to community care provision give insufficient attention to an individual’s rehabilitative potential, and, via well-meaning attempts to substitute function with assistance, may result in a premature reduction in important physical and social activities (e.g. shopping and cooking). Older people may become entrenched in a ‘sick role’, characterised by an absence of self-motivation, and the view that because they are aged or unwell they must remain dependent upon continuous professional management of care (Baltes 1996; O’Connell 2006; Verbrugge & Jette 1994). The funding mechanisms that underpin many services also limit the capacity for services to provide restorative care. Many services are funded for short, task-focused events (e.g., ‘please provide one hour of domestic cleaning’), which makes it difficult to use a flexible, goal-oriented approach that would underpin a more restorative program (e.g., ‘please help this client to purchase and use a light-weight vacuum cleaner’; Ware 2002). Some staff may also believe that bed rest is beneficial for a frail or sick older individual, despite considerable evidence to the contrary (Baker 2006). Staff may exacerbate this situation by emphasising task completion and doing as much as they can for the client, rather than trying to assist the client to do things for themselves.

Most approaches to community care provision give insufficient attention to an individual’s rehabilitative potential.

Current practice within community care services for frail older adults also contrasts sharply with the highly progressive movements that have occurred with other groups in developed countries over the previous 50 years. These movements include the concepts of normalisation and social role valorisation, which transformed approaches to the management of intellectual disability (Wolfensberger 1972), the large-scale deinstitutionalisation of people with psychiatric and intellectual disabilities, and emergence of more flexible community management models (Killaspy 2006; Mansell 2006), and, more recently, the chronic disease self-management movement from the US (e.g., Chodosh et al 2005). Older adults have not been entitled to the same ‘empowerment-oriented’ and independence-focused approaches as other groups with disabilities. As the highly educated and proactive baby boomer generation begins to enter retirement age, criticism of outmoded approaches is likely to intensify.

Future availability of carers

In the 1990s, considerable concern was expressed about the future availability of carers for frail older people. Reasons for anticipating a potential decline in informal care include declines in family size (Clarke 1995) and the proportion of older people who live with their children (Grundy 1995); rises in divorce rates (Clarke 1995), childlessness (Evandrou 1998) and employment rates among married women (Doty 1986); and changes in the care preferences of older people (Phillipson 1992; West et al 1984) and the nature of kinship obligations, especially in relation to filial responsibilities (Finch 1995).

In response to this concern, Carers Australia commissioned the National Centre for Social and Economic Modelling (NATSEM) to examine demographic and carer data from the Australian Bureau of Statistics (NATSEM 2004). The study projected a significant increase in the numbers of older people likely to need informal care in Australia between 2001 and 2031 along with a smaller increase in the numbers likely to be carers. At the same time, shifts in the composition of the disabled and carers’ populations were also projected, and both were predicted to include higher proportions of older people. Hence, there may well be increasing pressures on informal carers in the future. This, however, is not necessarily a cause for panic. Other OECD countries have already met the demands of the changing population structure that Australia is expected to encounter in the next few years.

Emerging directions in service reform

More convincing evidence of the effectiveness of community care began to emerge from a modelling exercise using data from the channelling demonstration (Greene et al 1995). The authors argued that much of the failure to find convincing evidence for the efficacy of community care was due to design shortcomings in most of the earlier evaluations, particularly the failure to disaggregate the effects of particular kinds of services for particular groups of clients. Green et al went on to develop a transition probability model and used data from the channelling projects to show that more effective outcomes could have been achieved with different distribution of the same resources.

The purpose of provision of community care has generally been cast primarily in terms of reducing use of residential care. However, some authors (Benjamin 1999; Bishop 1999; Kane 1999; Stone 1999) have proposed a much wider range of goals at individual, familial and societal levels. Feldman (1999) consolidated these into lists of 10 individual-level goals and 13 societal-level goals, and commented that there are possible inconsistencies and trade-offs between these multiple goals.

The most recent formulation of the targeting debate in the US was set out in 2003 by Weissert and colleagues (1988, 2003). Weissert analysed home and community care in the US over more than three decades, discussed several longstanding shortcomings in existing targeting policy, and proposed an alternative called ‘titrating’. This model suggests that simple ‘in or out’ targeting should be replaced with an approach that takes account of the risk (R) of adverse outcomes, the effectiveness (E) of home care services in mitigating the risks and the value (V) of the outcomes achieved relative to those avoided. The ERV model calls for titrating care rather than targeting clients. The proposed titrating model would be generous in eligibility — that is, access to services would be relatively easy — but the number of resources actually allocated to each client would be carefully calibrated. The ERV model does not deny any services to low-dependency clients, but allocates more services to high dependency clients only when the additional inputs will achieve a cost-effective reduction in risk of an adverse outcome.