Pearls and Irritations

Getting Australian Health Services right depends on delivering both Aged Care & Health Care effectively for frail ‘high risk’ older-old people. Reducing inappropriate hospital admissions, shortening length of stay, returning frail people to their homes rather than Residential Care, all depend on accessible, locally based, Community Aged Care assessment support and management systems. For around 30 years a simple, geographically based, Australian system – State Geriatric Medicine Teams with Commonwealth Aged Care Assessment Teams (ACATs) – provided local access for many frail older people and up-to-date information on the complexities of local Aged Care services. This system is being dismantled – but what is replacing it?

The History:

In 1982 the Commonwealth put out the persuasive McLeay Report “In a Home or At Home”. From the mid-1980s Commonwealth Health, together with State based Geriatric Services, set up local district Aged Care Teams (combining state funded Geriatric Services with Commonwealth funded ACATs) working with Community Services (HACC), Residential Care and GPs on common local boundaries. In NSW 22 District Geriatric Teams were developed for metropolitan populations of ~250,000 (18 in Sydney, 2 in Illawarra, 2 in Newcastle); 9 Regional Teams served variable rural populations. This process was duplicated across all States with ~170 local ACATs covering Australia (~66% being funded to provide ‘extended’ care)*. ACATs & Geriatric Teams were famed world-wide as an inclusive, equitable, innovative approach to Aged Care & Health Care for frail older-old people. It was far from perfect; had variable penetration; was variably effective for local reasons (e.g., Queensland Health was then un-regionalised) – but generally worked at a local level.

In April 2012 a new 10 year Commonwealth aged care reform program “Living Longer Living Better” was released, with its emphasis on “consumer-directed care”. Stated aims included: more support at home; better access to residential care; increased recognition of carers; more support for people with dementia; better access to information; utilising the market; encouraging businesses to invest and grow*. The changes commenced in 2013-2014 with: new Home Care Packages; My Aged Care – a centralised entry point contactable only by phone or internet; then a tender process for new Regional Assessment Services. The final implementation phase of a new system was set for 2017 to 2022.

The Issues:

In terms of access equity & coordination, the pre-existing Aged Care system has been fragmented & not effectively remodelled for the future. Components are put to three year tender for multiple operators to pursue on fragmented and changing geographic bases. Replacing the 1980s models would not be a problem if alternate solutions were effective, or more equitable, or financially intelligible, or even easier to access & use for less advantaged older-old Australians and their family carers. They are not.

The new system fails the vulnerable older-old in most need – the ‘cognitively frail’ with less capacity for self-management, less computer literate, less well off. It is devised for ‘young-old’ people & more switched on carers, but even they are finding it difficult to access & understand the complexities and interfaces. Individual local services (Community Nursing, Home Care, Transitional Care, Hospital-in-the-Home, Ambulatory Care) are intact, even proliferating, but form a fractured uncoordinated mess for the ‘at risk’ old. Assessment – by Regional Assessment Services (valuable but locally divided); ‘My Aged Care’ (centralised, internet and phone accessible); residual ACATs; private or not-for-profit Assessment Services – is not reasonably accessible for older-old people in most need. Communication is poor across fragmented assessment services for those whose job it is to assist at a local level – family carers, community nurses, social workers, GPs, Geriatric Teams, or discharge planners.

The motivation was good – equity, innovation, flexibility of access for “person-centred care”. However, the new system embodies unproven or dated concepts of ageing: a mistaken belief that ageing per se causes disability; a belief that public aged care systems are less efficient or innovative than private systems – hence weakening public responsibility for Aged Care; three yearly tender, on theoretical grounds of the value of competition over continuity of care; an acceptance of “market forces” (which do not operate effectively or efficiently in Aged Care) hence privatising without clear evidence of benefit. The result is a growing but fractured system, good for healthy competent older people – but increasingly inoperable for frail ‘older-old’ and disadvantaged carers, resulting in a poorly accessible, complex, headless beast of a system.

Steps to Solutions?

“You should turn the clock back if it is telling the wrong time”  John Kay Economist – ‘Other Peoples’ Money’ 2015.

We may not need to turn the clock back; but – to mix metaphors – we should not throw the babies out with the bathwater.

• Essentially we need to keep the benefits of new approaches to Community Aged Care that are valued by independent older people. At the same time, we need to restructure an accessible local district public interface between Community Aged Care, Primary Care and Hospital Care for the ‘at risk’ older-old. Commonwealth coordination of community Aged Care with State Health Care worked for 30 years. It will be even more essential as the baby boomer population reaches ‘older-old’ ages in the 2020s to 2030s.

• The ‘young-old’ (60 to 75 years) – 90% active, mobile, cognitively competent –need better chronic disease interventions, but not usually complex Aged Care Systems across local Community and Hospital Interfaces*. Aged Care solutions are mainly for the ‘older-old’ (75 to 100+) who, like old wines, do not travel well. Their rising needs are driven, primarily, by the corollary of current ‘healthy ageing’ and compression of morbidity to late-life – cognitive frailty, cognitive decline, dementia – with reduced capacity for decision making*.

• Primary care, community aged care, residential care, hospital care – can’t work in isolation or by pushing individual barrows. A combined Commonwealth State approach to coordinating community Aged Care interfaces with Aged Health Care has worked in the past. It will be essential as the baby boomer population reaches ‘older-old’ ages in coming decades.

Professor Tony Broe AM, BA, MB;BS (Hons), FRACP, FACRM

UNSW Conjoint Professor of Geriatric Medicine

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