CHAPTER 8 The aged care sector: residential and community care
In this chapter, we investigate health care for older Australians. We will look at statistics about the increasing number of older people and then consider their health needs along a continuum of increasing dependence from the well elderly, through hospital care and community care to residential care. At each point, we will consider the challenges faced by health care providers. We will illustrate some points by referring to Jane, a nursing student who works in aged care (see case study). The age of 65 years has traditionally been considered the start of old age but our discussion will mention those in the 55 to 64 years age group since this period is critical in determining life chances in the years ahead.
Like other aspects of health care, aged care has become an issue of intense political debate. Governments want to minimise the costs of providing care for the elderly but no politician wants to be seen as denying care to older members of the community, depicted as vulnerable people who have worked hard all their lives. One response to these dilemmas has been a shift from welfare-based provision of services to a market-driven approach, where low-cost services are targeted at those in need while richer older people are expected to contribute to the costs of care. There have been frequent changes to the regulations that determine who is eligible for low-cost care, and a new industry of financial planning has evolved to help older Australians arrange their finances to qualify for subsidised care. As a result of this complexity, interest groups have become increasingly vocal in their demands for aged care services to be provided in a manner that is equitable, easy to understand and predictable.
The number and proportion of older people in Australia have been increasing for several years. There was a big increase in the number of births between 1946 and 1961, with over 4 million Australians born as people recovered from the hardship of World War Two (Culture and Recreation Portal 2007). These baby boomers are now reaching old age. Large numbers of immigrants arrived in the post-war period and these people, too, are growing older. We are also living longer. Life expectancy increased by over 20 years in the period 1901–2001 (see Table 8.1) and there has also been a decline in the birth rate, magnifying the proportion of older people. There is concern about whether there will be enough ‘young’ people in future to pay taxes and provide the care needed by the growing number of ‘old’ people. In response, the Australian Government introduced substantial financial incentives for new mothers in 2001 and there has been an increase in births since 2002 (Australian Bureau of Statistics [ABS] 2007b).
|Year of birth||Males||Females|
Source: Hogan 2004
A closer look at the statistics reveals the extent of these changes. At the 2006 Census, 24.3% of the population was aged 55 or over, up from 22% in 2001 (ABS 2007b). Figure 8.1 shows that the increase in the number of people aged 85 and over is particularly striking (ABS 2006f) and this is the age group that is most likely to require health care (McCallum 2000). Even so, a decline in health is not inevitable as people get older. The challenge for health care workers is to help people maintain their wellbeing as they age so as to prevent or delay the onset of illness.
This section will look at healthy older people and those with minimal health impairment who live independently in the community. Throughout the lifespan, health and class position are closely related. One of the major determinants of class position and financial status is paid work. People who have had jobs that are fulfilling, adequately paid and in safe surroundings for most of their lives will be healthier and better off financially as they approach old age than others. This benefit also extends to their partners.
Traditionally, male employees had to retire from paid work when they turned 65 and women at age 60, regardless of their health or ability to perform their work. This had serious implications for individuals and for the national economy. Work plays a major part in defining self identity and people forced to retire felt worthless, leading to diminished mental health. Retirement also confirmed that they were now ‘old’. Compulsory retirement no longer exists for most Australians. While many still choose to retire in their sixties the Federal government has put incentives in place to encourage older people to stay at work and reduce the taxation burden on younger Australians.
Retirement also marks the time when people review their housing needs. One option is a retirement village, designed for and restricted to people over a specified age, usually 55 years. This is a rapidly growing sector of the Australian housing market (Clark & McCann 2003). It is market-driven, with villages offering not simply a home but a lifestyle and community. Some resemble up-market holiday resorts with sports facilities, restaurants and community activities. These villages appeal to affluent, sociable retirees but in turn may demand a high level of conformity to group norms (Clark & McCann 2003).
Retirement villages may offer higher levels of care, with serviced apartments or residential facilities for those unable to care for themselves. This attracts people who wish to age in place, believing that they will not have to move if they become frail. However, access to care depends on an assessment of health and social needs and a seamless transition to higher-level care cannot be guaranteed.
Older people who do not own a home face uncertainty as they age. Government investment in public housing has declined significantly since the 1990s (ABS 2005c), leaving people dependent on the private rental market for housing. Their health may deteriorate if they have to economise on food, heating or cooling due to high rents. There is some public housing for older people, while churches and charities operate low-cost retirement villages, but demand for these exceeds supply. People may have to leave family and friends behind as they move to a new area to find affordable housing.
In this section, we will examine older Australians’ use of hospitals. Although many older Australians consider their health good or excellent, the incidence of chronic illnesses increases with age (AIHW 2002). As a result, hospitals admit a disproportionate number of older people. For example, in 2005–06 people aged 55 years and over comprised 51% of all hospital admissions and 61% of patient days. They were likely to be admitted to hospital more often while those aged 75 years and over also had longer hospital stays than other adults (AIHW 2007a). One reason why older people have more frequent and longer hospital stays is co-morbidity, the presence of more than one condition requiring treatment; for example, a fracture and diabetes, or pneumonia and dementia. The likelihood of co-morbidity increases with age (AIHW 2007b).
Older patients are admitted to both public and private hospitals. As discussed in Chapter 5, many older Australians maintain their private health insurance cover despite its cost, believing that it gives them choice and greater access to care. Meanwhile, insurance companies have to meet the escalating costs associated with older patients. This is a consequence of the market model of private health insurance in Australia. In turn, the fact of having private health cover may increase demand for care. Walker et al (2006) found that the wealthiest quintile of people aged over 60 years in NSW was more likely to be hospitalised than others of the same age, despite having generally better health. For example, they were admitted to private hospitals for procedures such as screening tests or chemotherapy because they had health insurance. Patients without insurance underwent these procedures as outpatients in public hospitals. This suggests that a review of policies governing hospital admission for insured patients may help to contain the costs of elder health care.
Another way of managing the costs of hospital care for the elderly is to ensure that their hospital stay is as short as possible. This can be problematic if patients are unable to return to their homes and must remain in hospital until residential care is available. In 2005–06, 7% of patients went from hospital directly to residential aged care (AIHW 2007a) and one Queensland study found that patients sometimes waited up to 6 months for a place in residential aged care (Hegney et al. 2003). The term bed blocker is used to stigmatise older patients who occupy hospital beds for longer than clinically necessary while awaiting vacancies in residential aged care (Fine 2001; Millar 2000). Partly this reflects new public management thinking that families and patients should fend for themselves in the marketplace. Discharge planning minimises delays but patients and their families may need time to consider care options. Incidents such as falls or strokes occur without warning, leaving independent older people suddenly dependent on care and support for the rest of their lives.
The great majority of older Australians live at home, including 89% of the 1.4 million older people who have disabilities (ABS 2006j). Community care helps people who need assistance to remain in their own surroundings. It includes formal services coordinated by government and informal care from family and friends. In this section, we shall examine the provision of community care, the rhetoric informing policies of community care, and the challenges confronting it.
In the 1950s and 1960s, community groups and municipalities started to develop services for elderly people living at home and their carers. These services were fragmented, not always needs based and recipients had little voice in how they were run (Walker-Birckhead 1985). At the same time, the Federal government was spending heavily on nursing homes for the elderly, informed by a perspective that saw ageing as a medical problem (Healy 1990). The establishment of the Home and Community Care (HACC) program by the Federal government in 1985 signalled a major policy shift to provide services based on needs rather than age alone (Healy 1990). HACC is jointly funded by Federal, state and territory governments and aims to provide integrated services to the frail elderly and people with disabilities living at home (Palmer & Short 1994). Three smaller programs, Community Aged Care Packages (CACP), Extended Aged Care at Home (EACH) and EACH Dementia provide care at home for people with complex needs who would otherwise be in residential care (AIHW 2007c).
Home and Community Care and related programs provide services such as nursing care, meals, household assistance, transport and respite care. In 2004–05, 744 000 people received HACC services (Commonwealth Department of Health and Ageing 2007d). HACC providers include local government, community and charitable groups and private for-profit organisations who bid for contracts to provide services. Staff can be paid workers (such as Jane, see case study) or appropriately trained volunteers. The Quality Assurance Framework ensures consumer rights, quality of service and accountability (HACC 2002). Providers may charge clients, with the revenue used to fund further HACC services. The level of payment depends on clients’ income and services needed, and providers must respect principles of access, affordability and equity in determining fees (HACC 2002). Since providers determine fees, there can be inconsistencies between providers or geographic areas. In response to this, the Commonwealth government pledged to develop a more consistent and transparent approach to setting fees (Commonwealth Department of Health and Ageing 2004).
The intensive community care packages have much in common with HACC. In 2005–06, over 38 000 people received CACP, EACH or EACH Dementia packages. Each region has a limited number of packages, meaning that demand may exceed supply. On average there are 20 community care packages for every 1000 persons aged 70 years or over in a region and the Federal government aims to increase this to 25 per 1000 by 2011. Clients pay fees for these services, based on their income. For example, people on the age pension pay no more than 17.5% of their pension for their care (AIHW 2007c).
Home and Community Care and community care packages represent an intermediate position between welfare-based and market-driven approaches. No client is denied services because of an inability to pay, signifying a compassionate, welfare-based approach, while elements of the market-driven approach are apparent in the way that fees reflect clients’ income. The market approach is seen more clearly when service providers tender for contracts and compete against each other to deliver HACC services.
Traditionally, families provided care for their older members with little support from outside agencies. This informal care continues to be of major importance in helping frail older people stay at home. The burden of care does not fall evenly across the community. Of the 500 000 primary carers in Australia 70% are women and 29% are over 60 years old; 23% care for a parent; 43% of all carers, but 69% of those over 60, care for a spouse/partner. Over half of all carers spend 20 hours a week or more providing unpaid care. Many experience fatigue and reduced wellbeing as a result. The Commonwealth government supports some carers financially through carers’ payments that supplement or replace income from paid work (Commonwealth Department of Health and Ageing 2004). Even so, one estimate valued the work of unpaid carers at $19.3 billion, or almost double the amount paid by governments to welfare services (AIHW 2004b).
Government support for community care can be seen as a humane response to the expressed desire of older people to stay in their own homes rather than move to residential care. The Carers Association has promoted this view in their campaigns for assistance to family carers. At the same time, community care is not without problems. There may be gaps or duplication in services, due in part to the multiplicity of service providers in any one area. Linkages with other health care services need improvement (Commonwealth Department of Health and Ageing 2004). Even the best services cannot deliver all the care a frail elderly person needs, and the HACC program is consistent with a conservative political view that places primary responsibility for caring on families rather than governments. There is no denying that community care saves governments billions of dollars by reducing the need for residential care (Creelman 2002). These costs are transferred to families, particularly women, who bear the financial, physical and emotional costs of supplementing the care provided by community services (AMP:NATSEM 2006).
Overall, the challenge for community care in the future is to continue supplying high-quality services to the ageing population. Informal carers will play a central role and the availability of support for them will be an important political issue. We have seen rapid social change in recent years, including high divorce rates, geographic mobility, and women in paid employment for most of their lives (AIHW 2004b). Carers themselves are ageing. Community organisations struggle to find volunteers to deliver services, such as Meals on Wheels. These changes mean that there will be growing numbers of frail elderly without informal carers who will require additional HACC services. At the same time, HACC providers will rely on paid staff rather than volunteers, leading to higher costs. The need for residential aged care is also likely to grow.
Pause for reflection
Community care is based on the assumption that frail elderly people want to stay at home with the support of informal care. Is this assumption correct? What might be some of the problems of informal care for carers and those cared for? Does public investment in community care exploit informal carers? What should happen to people who do not have family or friends to provide informal care?