The Federal Government, which has long funded Australia-wide Aged Care Assessment Teams, commonly and often affectionately known as ACATs, has made a ‘surprise’ decision that it will privatise them from April 2021, with a tender to be held this year (30 December 2019).
This unexpected, and to many aged care workers irrational decision, has been received with deep concern and dismay by the numerous ACAT staff who have provided the backbone of experienced aged care assessment and family support over the past 30 years.
State employed teams of nurses, geriatricians, social workers and allied health workers have taken years to build and develop local aged-care health teams and support systems necessary to maintain older people in the community and where possible and appropriate, kept them out of acute hospitals and residential aged care facilities. With local knowledge these teams understand the complexity and co-morbidity of their clients and their family relationships and base.
To his great credit the NSW Health Minister Brad Hazzard has stated this move was not previously raised with him and lacks logic: “It seems pre-emptive and unreasonable to be effectively privatizing health aged-care services while the royal commission into aged care is still underway”.
The Morrison government and its immediate predecessors approach to aged-care reform since 2012 (Living Longer. Living Better program), is described as ‘embattled’, but is better categorised as an abject failure. It has failed to deal effectively with the country’s aged health care needs and what has developed is an aged-care crisis with social, political and health-related ramifications.
Senator Colbeck is correct to say there are inconsistencies in the service that need to be addressed with a national approach. However, this does not mean throwing the ACAT baby out with the failed aged care bathwater.
It must involve better development and integration of federal and state systems linking hospital aged health care, ACATs and community aged care and residential aged care with a more developed role for primary care, particularly in chronic disease intervention. The retention of state-based ACATs serving clients who are at high risk of hospital and health care in no way detracts from an emphasis on ‘consumer-directed care’, particularly for the young-old – a vital new initiative in community based aged-care.
ACATs were trialled from 1985 following the finding that around 20 per cent of residents were being inappropriately or prematurely placed in residential aged care (McLeay Report, “In Home or at Home” 1982).
Commonwealth Health together with NSW-based Geriatric Services set up a system of local district Aged Care Teams combining state funded geriatric services with Commonwealth funded ACATs, working with Community Services (HACC then CHASP), Residential Aged Care and GPs. In NSW 22 District Geriatric Teams were established for metropolitan populations of 250,000 and nine regional teams served rural populations of 30,000 to 100,000.
This process was expanded across all States with 124 local ACATs covering Australia. ACATs and Geriatric Teams were famed world-wide as an inclusive, equitable and innovative approach to aged care and health care for frail older people. It was far from perfect, had variable penetration and was variably effective for local reasons (Queensland Health was then un-regionalised) – but worked well at a local level.
A study of aged care services by Gray and Dorevitch in 2001, a decade before the 2012 Review, found that 556 hospitals (81 per cent) of the 690 hospitals surveyed reported having an on-site or visiting ACAT with 83 per cent of these hospitals having access through a service that visited on a regular basis. The aged care assessment program provided by 124 ACATs nationally could be regularly accessed in 97 per cent of Australians.
The largest proportion of referrals, for ACAT assessment in the gatekeeper role were, and still are, from hospitals, then other health service providers. In one NSW service, during 2006, 40 per cent of referrals came from hospitals and 23 per cent from other health service providers, 17 per cent family and friends, seven per cent self-referral and GP referral four per cent.
The 2012 10-year Commonwealth aged care reform program Living Longer Living Better was released with more emphasis on ‘consumer-directed care’. The changes commenced in 2013-14 with new home care packages, a centralised entry point contactable only by phone or internet and the tendering for new Regional Assessment Services. 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.
There is little evidence that any of these aims have been achieved and considerable evidence that the My Aged Care (MAC) system as a whole has failed.
In terms of access, equity and coordination the aged care system has become fragmented and is not effectively modelled for the future. Components, now including the ACATs, are being privatised with the risk off multiple operators employing inexperienced staff on fragmented and changing geographic bases. Replacing the 1980s models would not be a problem if alternate MAC solutions were effective, or more equitable, or intelligible, or even easier to access and use for disadvantaged older-old Australians and their family carers. They are not.
The new system overall fails those most in need: the ‘cognitively frail’ – with less capacity for decision-making and self-management, the less computer literate, and clearly those with any dementia. It is devised for ‘young-old’ people and more ‘switched on’ clients and carers, but even they are finding it difficult to access and 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 and the family carers who are often at risk of bureaucratic exclusion from the process on usually spurious grounds of ‘protecting privacy’ when it is the family carers who do the bulk (80 per cent) of aged care.
Community aged care, residential aged care, hospital care, primary 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 is needed. It will be essential as the baby boomer population reaches ‘older-old’ ages in coming decades. Let it not be further complicated by privatising yet another element of the aged care system – the ACAT.
Tony Broe is Senior Principal Research Fellow, Neuroscience Research Australia.