Submission to the Royal Commission into Aged Care Quality and Safety: Aged care program redesign

In this submission, CPSA responds to some of the questions posed in the Royal Commission’s Consultation Paper 1.

1. The principles for a new system

CPSA generally supports the design principles of the aged care system proposed by the Royal Commission. However, we do have a few comments.

The principle that deals with equity of access stipulates that equity of access should be “regardless of location”. CPSA is of the view that, for aged care to be delivered in a way that is “affordable and sustainable, both for individuals and the broader community”, it is fundamental for the aged care system to achieve a high level of co-location of care recipients. Co-location is maximised in nursing homes, but home care too can be delivered much more efficiently and affordably to both individuals and the broader community if care recipients are clustered, as they can be in retirement villages, residential parks, manufactured home estates and in specific seniors housing developments. This argument is developed in CPSA’s policy Right Housing, Right Aged Care, which was an attachment to CPSA’s submission to the Aged Care Royal Commission entitled The Family Home and Aged Care Funding. The design principles of Australia’s aged care system should reflect that this system needs to actively incentivize co-location of home care recipients in secure tenure. Perhaps the principle dealing with affordability and sustainability of the system could be amended to read: be affordable and sustainable, both for individuals and the broader community, recognising the crucial role of housing design, supply and location.

In the principle which deals with the aged care workforce, there should, in our view, be a reference to the adequacy of staffing levels, given the widespread inadequacy of staffing in residential aged care discovered during the course of the Royal Commission’s investigation thus far. We suggest this principle could be amended to read: enable the recruitment and retention of a skilled, professional and caring workforce in adequate numbers.

2. Making it simpler for older people to find and receive the care and supports that they need

Currently, My Aged Care is the first point of contact for people looking for care and support. Making My Aged Care (a website and a single phone number) the main contact point and source of information for people needing aged care is inappropriate for at least the current and the next generation of care recipients due to the limited computer literacy of many in these cohorts. The call centre approach can be useful but would require being staffed by people who are well-informed about aged care. Many people find the My Aged Care call centre impersonal and prefer face-to-face contact.

CPSA supports the creation of a network of local first-contact points, possibly co-located with local government authorities, which for the greater part already employ staff with responsibility for disability and ageing policy and services. These local contact points would have detailed knowledge of the aged care landscape in their area. By making GPs in the area aware that they can refer patients to this area contact point would establish a channel between those starting out to look for care and support and a knowledgeable person who can make suggestions and provide initial information about what options exist, the cost and the subsidies and the need to get an assessment done.

It is attractive to think that My Aged Care is more cost-effective than a network of local first-contact points, but it is far less efficient for the people starting to look for care and support. The cost savings achieved by My Aged Care are paid for with these people’s frustration and with delays in accessing appropriate care and support.

3. Information, assessment and system navigation

CPSA supports the creation of a network of local first-contact points. The functions of these first-contact points should be:

(1)      To outline to people seeking care and support what services are available;

(2)      To explain the process of assessment and enable people seeking care and support to apply for an assessment, i.e. a referral to an assessment currently provided by ACATs/RASs;

(3)      To outline how aged care is funded and what personal contributions must, and which personal contributions may, be levied and how, and to refer people to a financial advice service specialising in aged care funding;

(4)      To discuss the advantages of living in an area in which other care recipients live and highlight any incentives in place to move to such an area;

(5)      To follow up with people after this first contact to ensure they have the information they need to get care and support;

(6)      To promote to the community generally the benefits of ageing in ageing-specific housing, such as the proximity to services and reduced risk of having to go into a nursing home.

A specialised financial advice service such as the Department of Human Services’ Financial Information Service (FIS) would need to be set up so that the first-point-of-contact can make a referral to it.

Both the aged care assessment service and the aged care financial advice service should be run by organisations which are not part of an aged care provider organisation to avoid conflicts of interest.

As to system navigation and the roles of system navigator and care coordinator, CPSA holds the view that a public visitor scheme (distinct from the currently operating community visitor scheme and similar to the public visitor scheme for the NDIS) can perform welfare and wellbeing checks and assist a care recipient with managing changes in their care needs and system navigation. This would mean that public visitors covered both residential aged care settings and community aged care settings.

4. Entry level support stream

Current thinking seems to be that people receiving aged care at home means that they receive it at the family home. However, once people are no longer able to do the things they have always done to maintain and clean their house, when some, most or all activities of daily living become problematic, then certainly means-tested support should be made available as it currently is. However, at this point people need to be actively encouraged to look at what type of housing they need as their physical functionality continues to decline. This is an opportunity to orient people away from staying in a home that (1) may not have the accessibility required as mobility declines, that (2) may be too big, that (3) may not be located near services and that (4) may be in a more or less isolated location. The aged care system should not gear itself to keeping people in the home they have always lived in, it should gear itself to housing people where they can be better and more cost-effectively looked after.

As to funding of entry-level care, it is obvious that the mistake of the Home Care Packages program should not be repeated. If entry-level care is to be consumer-directed, funds should be pooled and notional personal accounts maintained in order to optimise cash-flow.

5. Investment stream

We again make the point that, before investing in home modifications and assistive technologies, analysis should take place if re-location rather than modification is a better and more rational option. Where it is, the incentives should be targeted at the care recipient to relocate. Incentives may also need to be made available to housing providers to build stock specifically for aged care recipients, to achieve co-location and avoid retrofitting accessibility features and assistive technologies.

We refer to our submission to the Aged Care Royal Commission: The Family Home and Aged Care Funding.

9. Financing aged care

We refer to our submission to the Aged Care Royal Commission The Family Home and Aged Care Funding.

10. Quality regulation

The Australian Government has been responsible for the residential aged care system for well over twenty years under the Aged Care Act 1997 and it  extended the home care program under that legislation into what is now the Home Care Packages (HCP) program. In recent years, it assumed control of the Home and Community Care (HACC) program, morphing it into the current Commonwealth Home Support Programme (CHSP) and moving disability care provided as part of HACC to the National Disability Insurance Scheme (NDIS), which the Australian Government is running.

The CHSP appears to be effective, but it was transferred to the Australian Government’s jurisdiction from HACC, where it was also effective. CHSP providers are now complaining about their work being hindered as a result of the transfer. A November 2019 newsletter published by a Meals on Wheels provider in far western NSW had this to say: “Before July 2015, if a client rang us, or walked in the door of Meals on Wheels, we would have a hot meal on their table the next day. Fast forward four years, and now, anyone wanting services provided (…) has to wait up to three weeks (or more in some cases) to get a meal on the table (…) because of the bureaucracy of MyAgedCare.” Community transport has also been disrupted as a result of the transfer of HACC to the Commonwealth.

Attempts by the Australian Government to institute the Home Care Packages (HCP) program under a consumer-directed care model have been less than successful. Anecdotally, the consumer-directed part appears not to be well-understood by many consumers and there is evidence consumers hoard funds paid into their HCP accounts administered by aged care providers. Also, care recipients receive their annual funding in a single payment and expend it over a year. It is not an efficient way to run the program, with so much cash sitting idle through the year.

The HCP program is also in competition with the CHSP as the HCP levels 1 and 2 deliver the same types of care as the CHSP.

Consider these observations together with the general state of residential aged care, a picture emerges of an Australian Government that develops and implements aged care policy that tends not to work very well.

Service delivery does not seem to be the Commonwealth’s strongest suit. It is not surprising that service delivery in Australia is typically the province of state and territory governments: in roads, public transport, education and general and dental healthcare. The Australian Government assuming control of the delivery of aged care is a twenty-odd year experiment gone wrong.

The question is whether state and territory governments should, individually, have operational and regulatory responsibility for aged care, and whether the Commonwealth’s role should be limited to collecting revenue and providing funding to the state and territories to deliver aged care.