Health and Ageing Budget submission 2002-03

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COUNCIL ON THE AGEING (AUSTRALIA)

Health and Ageing Portfolio

 

Submission to Federal Budget 2002-03

 

Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent
Melbourne Victoria 3004
Phone: 03 9820 2655 Facsimile: 03 9820 9886
Email: cota@cota.org.au

March 2002

CONTENTS

Summary of recommendations
Introduction

A. Aged care
1. Community care
2. Residential aged care
3. Carers and dementia care
4. Research and evaluation

B. Health
5. Private health insurance and hospital access
6. Pharmaceuticals
7. Discharge planning, Convalescent and palliative care
8. The co-ordinated care trials / Enhanced primary care
9. Bulk billing
10. Allied health services
11. Dental care
12. Health promotion
13. Mental health
14. Indigenous health

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SUMMARY OF RECOMMENDATIONS

A. AGED CARE

1. COMMUNITY CARE

Home and Community Care

1.1 Increase HACC funding by 20 per cent in 2002-2003 as an initial injection to enable a more appropriate level of care, then minimum 8 per cent indexation of the program to ensure continuing growth.

1.2 Adoption and implementation of the recommendations for improved resource allocation in the report Targeting in the Home and Community Care Program.

Community Aged Care Packages

Fulfil the election promise:

1.3 Commit $68 million to create an additional 6000 new places in Community Aged Care to relieve the pressure on residential aged care prior to new bed allocations coming on line.

2. RESIDENTIAL AGED CARE

Capital funding

Fulfil the election promises:

2.1 Increase of 30,000 places in next four years in aged care – 21,000 residential and 9,000 Community Aged Care Packages (6,000 CACPs receive new funding places of $68 million).

2.2 $100 million capital funding over 4 years for new and existing homes in rural regional and urban fringe areas.

2.3 Review the funding arrangements (vis a vis COPO formula). Commit an additional $200 million over 4 years to care funding

In addition COTA seeks:

2.4 Review capital requirements: assess capital needs and work with the sector to find solutions that enable quality accommodation without undue burden on the residents.

2.5 Industry Restructuring Initiative: extend the Initiative to assist those services that could improve the efficiency of their financial management, and therefore care.

The Residual Assets Limit

2.6 The residual assets limit be increased from 2½ times the annual single Age Pension to 5 times the Age Pension.

Consumer Information and Consumer Rights

2.7 The Department support the development of a model residential aged care data base and then its implementation and maintenance.

Aged Care Complaints Resolution Scheme

2.8 The Aged Care Complaints Resolution Scheme be reestablished as a separate authority utilizing as its guiding principles the Benchmarks for Industry-Based Customer Dispute Resolution Schemes released by the Minister for Customs and Consumer Affairs in 1997.

Accreditation

2.9 The Agency should be repositioned as an independent Corporation with adequate resourcing with the governing body being elected by the sector.

2.10 Increase the Agency's budget to provide education and information programs to increase consumer knowledge, understanding and involvement in the accreditation process.

Workforce planning and recurrent funding

2.11 Fulfil the election promise of $28 million over 4 years to attract nursing staff especially in rural and remote areas

2.12 Develop a workforce planning and training strategy to ensure the availability of appropriately trained staff for the aged care sector, and incentives for nursing staff to work in the sector.

2.13 Develop an appropriate indexation method for the funding of aged care that accounts for the cost of the workforce.

3. CARERS AND DEMENTIA CARE

3.1 Fulfil the election promise of $80 million additional funding over 4 years for carers.

3.2 Increased funding for the Carers Respite Centres.

3.3 In-depth research into the reasons that carers are finding difficulty in obtaining residential respite care and determine solutions.

3.4 Increased funding of $20 million a year targeted towards HACC respite services, with matching funding from the States and Territories to be negotiated.

3.5 Additional funding through HACC to specifically provide support services in households where there is a carer of a frail elderly or disabled person. Housework and personal care assistance should be provided to the person to ease the burden on carers.

Counselling and support for carers of people with Alzheimer's disease

3.6 Funding for counselling and training of carers of people with Alzheimer's disease in both the community and in institutions to ensure adequate knowledge of the complexity of the condition, the appropriate type of care and skills to assist the carer in best managing his or her role, in the context of an overall package which includes respite and support services. Specialist psychogeriatric units have an important role in providing community based services.

4. RESEARCH AND EVALUATION

4.1 Establishment of a well-structured and well-funded research program funded by Government to cover all aspects of aged care. Funding be established as a fixed proportion of the aged care budget, say, .001% (approx $5 million) per annum.

B. HEALTH

5. PRIVATE HEALTH INSURANCE AND HOSPITAL ACCESS

5.1 The Commonwealth contribution to public hospitals should be based on accurate assessment of need rather than any other factor.

5.2. Government to investigate means testing the 30 per cent rebate for private health insurance and remove the rebate for ancillary cover.

6. PHARMACEUTICALS

6.1 New strict controls on the direct and indirect advertising and promotion of pharmaceuticals.

6.2 Legally binding price/volume agreements with pharmaceutical companies particularly where sales have exceeded estimates on which the orginal price was based.

6.3 Greater transparency for the reasons for delisting drugs from the PBS, including consumer impact statements.

6.4 More resources for independent information and education about prescription medicines to both general practitioners and older people.

6.5 Ongoing funding for COTA's Wise Use of Medicines programs.

7. DISCHARGE PLANNING, CONVALESCENT AND PALLIATIVE CARE

7.1 Assessment of the need for and development of a national system of discharge planning, post-acute and convalescent facilities.

7.2 Assessment of the need for and extension of palliative care facilities.

8. THE CO-ORDINATED CARE TRIALS / ENHANCED PRIMARY CARE

8.1 Further allocation be made to extend the successful components of the Coordinated Care Trials and Enhanced Primary Care projects.

9. BULK BILLING

9.1 Ensure older people have access to bulk billing GP services throughout Australia

10. ALLIED HEALTH SERVICES

10.1 Older people's access to allied health services needs to be increased through the extension of Medicare items and the extension of co-ordinated care and Multipurpose Services

11. DENTAL CARE

11.1 Development of a national dental health policy with funding for a national dental health scheme.

12. HEALTH PROMOTION

12.1 A fixed proportion of the health budget dedicated to health promotion measures.

12.2 Extension of the National health priority areas to other causes of the burden of disease.

13. MENTAL HEALTH

13.1 Development of a national mental health strategy for older people.

14. INDIGENOUS HEALTH

14.1 Strategies to ensure indigenous peoples' access to mainstream health services used by all Australians

14.2 Strategies to develop specific services to meet the special needs of indigenous Australians.

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Introduction

The Council on the Ageing welcomes the broadening of the scope of the Health and Aged Care portfolio to Health and Ageing. COTA believes it imperative that the facts of population ageing are embedded in the Government's policy responses across the broad spectrum of issues in Health and Ageing. COTA also believes that cross-sectoral responses are needed to many issues that involve more than one department.

In the present term of office there are many challenges for the Government in the new Health and Ageing portfolio. This submission addresses those challenges and puts forward a number of recommendations as to how Government may resolve them.

Other matters relating to ageing issues are covered in the two other budget submissions:

Coming of Age: An Integrated Policy Framework for Australia's Ageing Workforce

Social Security and Social Support for Older Australians.

COTA sees the major challenges in the Health and Ageing portfolio as follows:

• achieving stability in residential aged care and tackling some of the endemic problems such as staffing shortages

• finding a new model for community care funding

• finding ways to stem the blow out in the cost to the public purse of the private health insurance rebate

• ensuring the integrity of the Pharmaceutical Benefits Scheme

• coming to grips with the need for a national policy and funding for dental care for low income Australians.

• addressing some of the structural problems in the health system such as poor convalescent and rehabilitation facilities.

The Government made a number of worthwhile commitments in the 2001 Federal Election campaign which are mentioned in this submission. However, a number of important areas were neglected.

The election of the Coalition to a third term of Government provides an opportunity to follow through on policy reform in important areas that have already been commenced and to instigate new areas of reform.

The National Strategy for an Ageing Australia

COTA is very pleased that the Minister for Ageing, the Hon Kevin Andrews MP, has officially launched the National Strategy for an Ageing Australia. In 1997, COTA with Aged and Community Services Australia, suggested to the then Minister, the Hon Warwick Smith, the creation of a National Strategy. Since then COTA has spent many months providing submissions to the 5 discussion papers.

Mr Andrews is commencing a community consultation process about the National Strategy with a series of community meetings in cities and regional centres. The main focus of the meetings will be to develop a set of practical initiatives that address the issues affecting older Australians.

COTA applauds the Government for following through on the National Strategy for an Ageing Australia. This process has engaged a large amount of community resources to date. It has considerable potential for delivering good policy outcomes for older Australians and the community at large.

The Budget context

The 2001 Federal Budget contained measures that benefited all older Australians. The Treasurer has indicated the 2002 Federal Budget will be tight. COTA believes that the 2002 Budget must look to assisting those older people in the greatest need. Programs including the Pharmaceutical Scheme are important to older people. Those who rely entirely or substantially on the Age Pension have no flexibility with their weekly income which is often completely committed.

COTA seeks the Government's commitment not to impose any new burdens on this group. Likewise, COTA seeks the Government's commitment to maintaining existing program expenditure.

A. AGED CARE

1. COMMUNITY CARE

Home and Community Care

Services provided through the Home and Community Care program (HACC) play an increasingly critical role in health maintenance of an ageing population. Community care represents an important complementary system to the health system.

A timely, adequate and appropriate level of community care can mean that a frail, older person or couple can continue to live at home for longer periods. This can mean less reliance on health services and residential care.

The people we are concerned about are generally capable of self care and independent living in the community but have difficulty with maintenance activities including maintaining a home and garden due to frailty or a low level of disability.

We believe that many older people have their living standards and health compromised because of lack of basic support services. The result can be premature admission to residential aged care or at worst hospital admission or death.

COTA was pleased that in the 2000 Federal Budget, the Government made attempts to draw additional resources into HACC.

This has been done, in part through the Veterans' Home Care Program (VHC) which is aimed at assisting veterans to stay in their own home and prevent admission to residential facilities. By allowing many veterans to access this program, the Government anticipated that there would be additional resources for older non-veterans in the mainstream HACC program. The Government estimated that up to 20,000 non-veterans could benefit. However, according to the Social Policy Research Centre evaluation, between January and June 2001, the program was taken up primarily by veterans who were previously not receiving home care services with only 20 per cent of participants transferring from HACC.

It may be well into 2002 until we could expect to see a flow through of benefit from this initiative. However, the Government must continue to ensure that HACC is adequately resourced.

The 1999 report Targeting in the Home and Community Care Program (National Ageing Research Institute and Bundoora Extended Care Centre (1999) Targeting in the Home and Community Care Program, Aged and Community Care Service Development and Evaluation Reports, July 1999-No. 37, Department of Health and Aged Care, Canberra) shows that there needs to be a fundamental reconsideration of how resources within the HACC program are distributed between competing priorities and between various levels of care needs. The VHC program was, in part, based on the Targeting report.

COTA supports the three tier structure proposed in the report:

Tier 1: Basic HACC – this level to be characterised by broad eligibility and open access.

Tier 2: HACC "Plus" – at a certain level of service use or identified need, clients would be referred to a Comprehensive Assessment Services. All additional services to be funded through brokerage funds. It is estimated that 15 per cent of clients would be eligible for HACC plus.

Tier 3: HACC "Exceptional Clients" – high need clients identified through the Comprehensive Assessment Services. This group would be funded through a pool of funds allocated on a case by case basis rather than HACC funds. It is estimated that 2 per cent of clients would be in the "exceptional" group.

COTA considers that this model would substantially assist in ensuring a better spread of resources between low, medium and high need clients.

Recommendations 1.1 Increase HACC funding by 20 per cent in 2002-2003 as an initial injection to enable a more appropriate level of care, then minimum 8 per cent indexation of the program to ensure continuing growth. 1.2 Adoption and implementation of the recommendations for improved resource allocation in the report Targeting in the Home and Community care Program.

Community Aged Care Packages

State and Territory COTAs report that people are having increasing difficulty finding low care and high care beds. There are a multitude of factors including the time lag for new bed allocations to come on line and the closure of services in 2000. Given the impossibility of bringing new beds on line quickly, the continued immediate expansion of Community Aged Care Packages would assist in meeting some of the need.

Recommendation Fulfil the election promise: 1.3 Commit $68 million to create an additional 6000 new places in Community Aged Care to relieve the pressure on residential aged care prior to new bed allocations coming on line.

2. RESIDENTIAL AGED CARE

The Council on the Ageing is seeking the Government's fulfilment of its election promises in the next budget. The commitments are vital to ensuring the viability of the industry over the long term. Most important of all will be the review of the care funding formula in terms of the Commonwealth Own Purpose Outlays formula and the commitment of $200 million to improve funding over the next four years.

Restructuring of aged care

The reforms to residential aged care are now over 4 years old. COTA welcomed the Government's initial leadership in providing resources for the restructuring of residential aged care. This initiative needs to be maintained and extended. The commitment to assisting restructuring seems to have diminished.

Residents need a viable and sustainable industry which is able to deliver quality care. To achieve restructuring, new approaches will be needed and some of the current policies will need amending. The recommendations of the Two Year Review need to be implemented. COTA supports the re-establishment of the Industry Restructuring initiative.

Capital funding

Industry issues

COTA is becoming increasingly concerned that current accommodation bonds and charges are not adequate to enable the industry to meet 2008 Certification requirements. The industry reports that because of inadequate indexing arrangements, capital is being diverted to meet recurrent expenditure. Solutions must be found to meet capital shortages particularly in high care.

There is a very strong case for maintaining capital funding for facilities in depressed areas and facilities in rural and remote Australia. Facilities in these areas have viability issues not faced in major urban centres. Small facilities cannot achieve economies of scale. Bonds in depressed areas are hard to obtain as residential properties are of little value or cannot be sold.

Consumer issues

Bonds and accommodation charges are assessable and payable on admission. About one third of residents move or die within six months. Facilities go to great lengths to conduct assets tests for bond and charge assessment. This is a waste of provider staff resources for those people who leave so soon. COTA believes that both facilities and older people would benefit if the bond and charge assessments were undertaken after admission. There could be a recalculation of the draw down to capture the first six months. The benefits of a delayed assessment and payment would be: admission clearly on the basis of need; a chance for residents to realise non liquid assets; a less hurried assessment; time to enable the resident to move to another service; less administrative cost for the provider.

The maximum Accommodation Bond Interest Rate is approximately 8.28 per cent. This rate of interest is too high particularly as providers are not required under legislation to quarantine bonds for capital improvements.

Recommendations Fulfil the election promises: 2.1 Increase of 30,000 places in next four years in aged care – 21,000 residential and 9,000 Community Aged Care Packages (6,000 CACPs receive new funding places of $68 million). 2.2 $100 million capital funding over 4 years for new and existing homes in rural regional and urban fringe areas. 2.3 Review the funding arrangements (vis a vis COPO formula). Commit an additional $200 million over 4 years to care funding In addition COTA seeks: 2.4 Review capital requirements: assess capital needs and work with the sector to find solutions that enable quality accommodation without undue burden on the residents. 2.5 Industry Restructuring Initiative: extend the Initiative to assist those services that could improve the efficiency of their financial management, and therefore care.

The Residual Assets Limit

COTA believes that the residual assets limit of two and half times the annual single Age Pension for people entering residential aged care after paying accommodation bonds is inadequate. COTA continues to receive reports of some residents having no income left after paying medical, pharmaceutical and continence aid co-payments. In a survey of COTA members, average age 70, 50 per cent had private health insurance. This alone at top level care would absorb 15 per cent of the pension retained by the resident.

The ongoing costs that must be met by the resident:

• dental care
• medical copayments
• pharmaceutical copayments
• over the counter drugs
• allied health services including podiatry, physiotherapy, speech therapy (these are prescribed services only in high care facilities)
• custom-made aids and motorised wheelchairs
• incontinence aids for lower level dependency residents
• hairdressing
• personal clothing
• gifts or loans to family
• cost of outings
• funeral expenses
• psychological counselling

Recommendation 2.6 The residual assets limit be increased from 2½ times the annual single Age Pension to 5 times the Age Pension.

Consumer Information and Consumer Rights

A number of studies have been carried out on behalf of the Department of Health and Ageing on consumer information needs. To COTA's knowledge, these reports on consumer information have not been released. The situation remains that seeking accommodation for a relative is a horrible task due to the paucity of information and advice. In one Queensland study (http://www.qls.com.au/infolatest/lcacreport.htm), not one resident had the benefit of independent legal or financial advice.

This situation is intolerable for the tens of thousands of families seeking care for their loved ones each year. Older people and their carers need access to information and advice regarding aged care through a multitude of distribution points, e.g. seniors information services, libraries, older people's organisations, etc.

A website directory is an important way to achieve ready access to up-to-date aged care service information. Unfortunately, the commercial attempts to produce website or printed directories lack the back-up support of advice.

Consumer information is fundamental to the development of a strong culture of consumer rights in residential aged care. COTAs have a network of Seniors Information Services in most States and Territories that would provide even better services with adequate funding.

Recommendation 2.7 The Department support the development of a model residential aged care data base and then its implementation and maintenance.

Aged Care Complaints Resolution Scheme

The Division of Consumer Affairs within the Department of Treasury has issued Benchmarks for industry-based customer dispute resolution schemes. When compared with these Benchmarks, the current aged care complaints resolution system does not rate well.

The National Aged Care Alliance has recently released a report Resolving Aged Care Complaints. The Alliance recommends:

• publish and make publicly available standard format annual reports of the Complaints Resolution Scheme, the Aged Care Standards Agency and the Commissioner of Complaints

• establish conformance to and on-going performance evaluation against the Benchmarks for Industry Based Customer Dispute Resolution Scheme

• provide clear consumer information translated to meet the cultural and linguistic diversity of older Australians on an integrated approach to quality care services, which included complaints and standards mechanisms

• support and resource the continued development of robust internal and external complaints systems that have fair and transparent processes

Much more could be said, but suffice to say, the Aged Care Complaints Resolution Scheme is structurally flawed and needs to be established as an independent authority that conforms to the Benchmarks issued by The Commonwealth Treasury and is responsible to Parliament.

Recommendation 2.8 The Aged Care Complaints Resolution Scheme be reestablished as a separate authority utilizing as its guiding principles the Benchmarks for Industry-Based Customer Dispute Resolution Schemes released by the Minister for Customs and Consumer Affairs in 1997.

Accreditation

The Aged Care Standards and Accreditation Agency succeeded in conducting assessments of all residential aged care facilities in the first round. The Agency has been drawn into controversies in individual facilities. This is unfortunate as there is now confusion throughout the sector regarding accreditation, compliance and complaints. Accreditation is a process of continuous improvement and should be seen as a separate function to the compliance activities of the Department.

Recommendation 2.9 The Aged Care Standards and Accreditation Agency should be repositioned as an independent Corporation with adequate resourcing with the governing body being elected by the sector. 2.10 Increase the Agency's budget to provide education and information programs to increase consumer knowledge, understanding and involvement in the accreditation process.

Workforce planning and recurrent funding

The election promise of $28 million over four years to attract nursing staff particularly in rural and remote areas is welcome. But more will need to be done to solve the workforce issues in the aged care sector.

One of the most important elements of developing a world class aged care system will be to ensure that there is an adequate workforce to meet needs in the future.

Employment in aged care services requires sophisticated and ongoing training to ensure staff have the most up-to-date skills and knowledge in the area.

The aged care industry must be prepared to offer conditions and pay salaries that will attract the highest calibre nursing staff and other care workers. Concern is being registered with COTAs around Australia that staffing levels have deteriorated. The industry reports that it cannot compete for nursing staff when their salary levels are lower than those paid in the acute sector. The indexation method used by the Department, the Commonwealth Own Purposes Outlays (COPO) index, is unsuitable to the aged care industry as it does not take into account the cost pressures faced by the sector. The inevitable consequence of insufficient indexation is the reduction in both the number of and skill level of staff.

There is an increasing number of high care residents in both high and low residential care services. Complex, chronic conditions and episodic acute care require skilled responses.

Recommendations 2.12 Fulfill the election promise of $28 million over 4 years to attract nursing staff especially in rural and remote areas 2.13 Develop a workforce planning and training strategy to ensure the availability of appropriately trained staff for the aged care sector, and incentives for nursing staff to work in the sector. 2.14 Develop an appropriate indexation method for the funding of aged care that accounts for the cost of the workforce.

3. CARERS AND DEMENTIA CARE

The Government's $80 million commitment to carers is very welcome. Over 4 years it is earmarked to be spent as follows:

$10 million for respite
$ 30 million for ageing carers of people with a disability
$ 20 million for carers of people with dementia
$10 million for equipment and transport
$10 million for support services.

The election commitments and initiatives from recent Budgets and the 1998 Staying at Home package mark significant advances in terms of policy for special care needs in the areas of dementia and policy for carers.

Nevertheless, it must be recognised that there are significant community needs in these areas that are only now gaining recognition and that there is a backlog of need. We welcome the progress made to date but there is still a long way to go. A number of those needing care and their carers have also been affected by increased user charges for health, aged care and community care services.

The difficulties that carers face cannot be underestimated. Many are older people who are caring for a loved one. They may have their own health problems to contend with. There may not be a family or community network to support them and they may be at risk of depressive illness.

For younger carers, the caring role may mean that they are unable to work or work full time. This can have very significant long term social and economic implications such as retirement savings.

The caring role, while having its rewards, can involve immense emotional, physical and economic pressures for carers. Caring for a seriously ill or disabled person is a difficult and challenging undertaking. People who undertake this role should be given the maximum level of support available. However, they should also have a choice as to the extent and nature of their caring roles. Appropriate community care, residential care and respite services must be available when needed.

For carers of people with dementia, there are special support needs. Alzheimer's disease can develop over a very long period of time and there are different phases of the disease. The carer will have evolving support needs over this time.

COTA has identified several priorities for the 2002 Budget.

Respite care

Respite is of paramount importance to carers. Carers need a range of options which provide them with regular breaks from the demands of caring. Through the aged care reforms and the 1998 Staying at Home package, there has been increased access to respite care but utilization has been below the targets. Despite the allocation of new resources and a modest increase in utilization, particularly in high care, there is wide spread dissatisfaction. This dissatisfaction relates to the lack of availability and flexibility. There is still a considerable level of unmet need for people in high care situations for both in-home and residential respite services.

People with dementia or sensory loss may be unable to use residential or centre based respite. For this group in-home respite must be available.

Recommendations 3.1 Fulfil the election promise of $80 million additional funding over 4 years for carers. 3.2 Increased funding for the Carer Respite Centres. 3.3 In-depth research into the reasons that carers are finding difficulty in obtaining residential respite care and determine solutions. 3.4 Increase of $20 million a year funding targeted towards HACC respite services, with matching funding from the States and Territories to be negotiated.

Community care

It is essential that carers are supported by adequate services provided through HACC. The strains of the caring role can be substantially eased by home help and other services to the frail elderly or disabled person being cared for.

Recommendation 3.5 Additional funding through HACC to specifically provide support services in households where there is a carer of a frail elderly or disabled person. Housework and personal care assistance should be provided to the person to ease the burden on carers.

Counselling and support for carers of people with Alzheimer's disease

Alzheimers disease is a complex condition requiring specialised counselling and training of carers for the benefit of both the person and the carer. In addition, there is emerging evidence of a range of innovative, ameliorative measures that can be employed for people with Alzheimers disease. Psychogeriatric units such as operating by the South Australian Alzheimer's Association provides a good model of a service that can provide appropriate supports and innovative interventions.

It is critical that counselling and training should not be seen as a substitute for respite and support services for Alzheimers carers but rather as a facet of an overall package of support. An important point about adequate and appropriate training for Alzheimers carers in residential aged care, is that it results in improvements to the quality of care of all residents.

Recommendation 3.6 Funding for counselling and training of carers of people with Alzheimer's disease in both the community and in institutions to ensure adequate knowledge of the complexity of the condition, the appropriate type of care and skills to assist the carer in best managing his or her role, in the context of an overall package which includes respite and support services. Specialist psychogeriatric units have an important role in providing community based services.

4. RESEARCH AND EVALUATION

COTA believes that there is an urgent need for a much higher level of Commonwealth funded research into "best practice" for both residential and community care. COTA, as the publisher of the Australasian Journal on Ageing is very aware that there is a paucity of "best practice" articles. Practitioners report they have little time and few resources to research and report their work.

Research needs to focus on a number of key areas:

• quality assurance in aged care

• international standards in aged care

• dementia care

• other special care needs such as that relating to people with disabilities who are enjoying increased longevity and the needs of carers in a wide range of situations.

The Australasian Journal on Ageing advisory committee which consists of some of Australia's leading ageing researchers would be able to provide advice as to how such a research program should be structured, as well as key research priorities.

Recommendation 4.1 Establishment of a well-structured and well-funded research program funded by Government to cover all aspects of aged care. Funding be established as a fixed proportion of the aged care budget, say, .001% (approx $5 million) per annum.

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B. HEALTH

There were no major promises made in the health care area in the Federal Election campaign. Nevertheless, COTA is concerned about the potential for cutting important health services or implementing harsh user pays components in the health system to wind back costs particularly in sensitive areas for older people such as the Pharmaceutical Benefits Scheme.

At the same time, the private health insurance rebate represents a major loss of potential funds to the health system with no evidence that pressures on public hospitals are reduced and a growing concern that private hospitals may be favoring some types of more profitable patients over others especially older people with complex or multiple conditions.

There are also important systemic problems in the health system. The most important of these relate to the shortage of aged care places, and convalescent and rehabilitation facilities which means that many older people are spending unnecessarily long periods in hospitals. There is still no commitment to fix the black hole of public dental care for low income people.

For the 2002 Budget, COTA believes that the Government must:

• preserve the integrity of important programs especially in pharmaceuticals without imposing harsh user pays requirements or rationing systems

• find ways of reducing the rising costs of the private health insurance rebate.

• address some of the systemic problems in the hospital system around access to aged care, convalescent and rehabilitation facilities.

5. PRIVATE HEALTH INSURANCE AND HOSPITAL ACCESS

One of the most critical tasks for the Government in the 2002 Budget is to find ways of stemming the haemorrhaging of public funds into the 30 per cent private health insurance rebate. The rebate has:

• blown out costs now to around $2.3 billion per annum

• failed to put caps on the price of private health insurance

• failed to improve accessibility for older people in either public or private hospitals

• helped to create perverse incentives in private hospitals to discriminate against older "medical" patients with complex conditions.

• provided greatest assistance to high income earners and created the grotesque situation of subsidising high earners for dental care while low income earners have to wait years for treatment in public clinics.

COTA is most concerned about access issues in both private and public hospitals. Private hospitals are motivated to take the most profitable patients. Public hospitals are motivated to discharge older people prematurely.

Some policies include exclusions for important categories of medical intervention for older people including joint replacements, coronary surgery and cataract surgery. As these are the areas for which waiting lists have traditionally been highest, people with these policies are unlikely to relieve pressures on public hospitals.

In addition there are serious questions as to whether increased private health insurance membership will relieve the pressures on emergency services in the public system. Emergency is an important area of admission of older people but most private hospitals are not able to provide intensive care and emergency treatment to the level of the public system. Less than one third of acute care hospitals in Australia are in the private system (Australian Institute of Health and Welfare (2000) Australia's Health, Australian Institute of Health and Welfare, Canberra, p 266).

Gap payments continue to be a problem for many people with private health insurance and deter many from admission as a private patient in a public hospital. There does not appear to have been a translation of high private health insurance coverage into reduced pressures on public hospitals covering reduced waiting times for non-urgent surgery and increased capacity for handling emergency cases.

COTA believes that the Commonwealth needs to carefully consider these limitations to its policy of increasing private health insurance membership.

It is critical that the Government evaluates the outcomes of its new policies in terms of real effects on access to health care.

The analysis of the effects of the private health insurance rebate undertaken by Stephen Duckett and Terri Jackson (Duckett S and T Jackson (2000) "The new health insurance rebate: an inefficient way of assisting public hospitals" in Medical Journal of Australia, Vol 172, 1 May 2000, p439) shows that "the subsidy cannot be justified on efficiency grounds, as, on the basis of available evidence and taking casemix into account, public hospitals are more efficient than private hospitals."

COTA believes that Lifetime Health Cover has been the correct response to the Government's concern about the decline in participation in private health insurance and will provide stability to the industry over the long term. However, the rebate for private health insurance is:

• inequitable in that it provides a subsidy to high income earners many of whom were in private health insurance anyway. High income earners are not particularly price sensitive to the cost of private health insurance.

• inefficient because of the greater efficiencies in the public system

• unsustainable because of the high costs involved and the marginal outcomes in relieving pressure on public hospitals.

• poorly targeted as it aims to increase the numbers of Australians with private health insurance rather than provide a rebate to people who use private health care including private hospitals.

Given that a large number of low to middle income earners have taken up private health insurance because of Lifetime Health Cover, there are difficulties in removing the 30 per cent rebate. However, responses include a means test the rebate so as to exclude high income earners from the benefit.

Recommendation 5.1 The Commonwealth contribution to public hospitals should be based on accurate assessment of need rather than any other factor. 5.2. Government to investigate means testing the 30 per cent rebate for private health insurance and remove ancillary cover.

6. PHARMACEUTICALS

Australia has a Pharmaceutical Benefits Scheme of which we can be proud. It provides affordable medication. But the scheme's integrity is under threat.

Access to pharmaceuticals is a critical part of the health and aged care system. Management of the costs of pharmaceuticals both to the Government and to the consumer ensures that people can continue to obtain the drugs they need to improve quality of life.

The growth in outlays has led to de-listing of some drugs from the PBS and older people have suffered as a result. COTA is most concerned about the large number of cases of older people who are finding that medications they rely on have been deleted from PBS. The loss of concessional prescriptions is a major cause of financial hardship for some older people.

COTA is very concerned about the intensive promotion of pharmaceutical products to general practitioners by pharmaceutical companies.

Government needs to balance the growth in outlays under the Pharmaceuticals Benefits Scheme against therapeutic outcomes. Any policy which aims to reduce the access of sick people to the medicines they need is inappropriate. Pharmaceuticals are a method of treatment under the terms of evidence-based medicine.

In addition, doctors, consumers and pharmacists need better education on drugs through the National Prescribing Service.

Doctors, consumers and pharmacists need better education on drugs which allow them to independently evaluate drug effects and uses.

The Council on the Ageing has particular concerns regarding the inappropriate use of medicines and the rapid growth in use of pharmaceuticals as a substitute for other forms of treatment amongst older people specifically. These factors, we believe, have contributed to the growth in outlays for the Pharmaceutical Benefits Scheme.

Our work with older people has identified the need for:

• more information and education about prescribed medicines for older people;

• better communication between consumers and health professionals about the wise use of medicines;

• strategies to encourage older people to manage their own medicines and improve the quality of consumer decisions about the wise use of medicines.

In 1996 and 2000 the Council on the Ageing ran highly successful national projects with Commonwealth funding on the Wise Use of Medicines which involved the training of older people to speak to groups of older people about the use of pharmaceuticals. The 2000 project has been carried out through a succcessful partnership with the Pharmacy Guild of Australia and COTA. We believe there is an ongoing need for the education of older people about pharmaceuticals using a range of appropriate methods.

Recommendations 6.1 New strict controls on the direct and indirect advertising and promotion of pharmaceuticals. 6.2 Legally binding price/volume agreements with pharmaceutical companies where sales have exceeded estimates on which the orginal price was based. 6.3 Greater transparency for the reasons for delisting drugs from the PBS, including consumer impact statements. 6.4 More resources for independent information and education about prescription medicines to both general practitioners and older people. 6.5 Ongoing funding for COTA's Wise Use of Medicines programs.

7. DISCHARGE PLANNING, CONVALESCENT AND PALLIATIVE CARE

Discharge planning and convalescence

COTA continues to receive reports throughout Australia – with some variations between States/Territories - about older people's premature discharge from hospitals, when they are still quite ill and without social or community supports. Reports of older people in acute care being labelled as "bed blockers" are also consistently received. COTA resents older people being identified as the problem when the problems are structural and the responsibility of governments.

In addition, COTA is increasingly concerned that older people are being turned away from private hospitals because of the lack of step down and convalescent facilities

COTA has long been concerned about the lack of discharge planning and the paucity of convalescent facilities throughout Australia, although we are unable to find information through the Australian Institute of Health and Welfare about these.

COTA believes that convalescent facilities or step-down facilities need to be much more developed in Australia. We observe the paucity of convalescent facilities has a number of undesirable consequences:

• premature discharge from hospital back into the community

• excessive pressure on community care services, which means that they are unable to fulfill their primary preventative purposes for people with low care needs.

• higher rates of readmission and relapse to hospital

• admission to permanent residential care to relieve the pressures on acute care but at the expense of a person's recovery and return home.

Acute hospital services need to be backed by adequate support services in discharge, post-acute, convalescence and rehabilitation facilities.

In an era of debate about the issue of euthanasia, it is particularly important that high quality palliative care is available for all terminally ill people who need it. In this context, it is important that people have a choice of care at home (including in residential aged care) or in a hospice. This implies a need for both hospices and services that can be accessed at home.

In the next 12 months, the renegotiation of the Australian Health Care Agreements will provide an opportunity to formulate better arrangements for the provision of convalescent and rehabilitation facilities and palliative care as well as standards for discharge practices in public hospitals.

Recommendations 7.1 Assessment of the need for and development of a national system of discharge planning, post-acute and convalescent facilities. 7.2 Assessment of the need for and extension of palliative care facilities.

8. THE CO-ORDINATED CARE TRIALS / ENHANCED PRIMARY CARE

Coordinated Care trials started in 1997 with the conclusion of the first round of trials, in December 1999. A second round of trials is underway. However, it is vital that the successful methodologies developed with Coordinated Care Trials begin to be implemented on a more universal basis.

COTA is particularly interested in the following aspects of the Trials:

• individualised care planning

• a more organised approach to prevention, early intervention and treatment

• pooling of funds

• linking of medical services with community services

COTA also supports initiatives in Enhanced Primary Care (EPC) encompassing case conferencing, health assessments, and care planning. COTA is currently piloting a peer education project to assist older people make full use of health assessments. Health assessments have the potential to reduce the need for assistance and more extensive care. (See report of a study in Julie E Byles "A thorough going over: evidence for health assessments for older persons" in Australian and New Zealand Journal of Public Health, v24 no2.)

Recommendation 8.1 A further allocation be made to extend the successful components of the Coordinated Care Trials and Enhanced Primary Care projects.

9. BULK BILLING

A serious pressure point for older people is the declining access to bulk billing. Due to the decline in bulk billing doctors, particularly in non-metropolitan Australia, older people are now contributing co-payments for GP services which were up until a year or two ago fully covered by bulk billing.

The loss of bulk billing is creating serious hardship for many low income older people with complex and chronic conditions. For an individual on a full age pension needing to see a doctor once or twice a week, his or her income can be reduced by amounts in the order of $6-$12 per week or more. This is yet another factor contributing to the financial hardship reported by many older people.

Recommendation 9.1 Ensure older people have access to bulk billing GP services throughout Australia

10. ALLIED HEALTH SERVICES

Medicare does not cover many important areas of treatment under the umbrella of allied health services such as physiotherapy, podiatry, chiropractic and psychology. Low income, older people have difficulty accessing these services if they have not taken out "extras" in private health insurance. However, insurance may not offer a large enough rebate to make the premium affordable, especially for people paying health insurance out of a full Age Pension.

Older people may gain more benefit from allied health services than from pharmaceuticals. These are often prescribed because other, more appropriate treatments are not affordable or accessible. However, the use of pharmaceuticals as the only form of treatment is a false economy if underlying conditions are not treated and lead to further deterioration which then need more expensive and radical treatments. (It needs to be recognised that pharmaceuticals do have an important role in delaying or minimising the effects of certain conditions however).

It is vital that those allied health services which are subsidised, especially hearing and optical, continue to meet the needs of the ageing population.

Access to allied health services need to be strengthened in rural and remote areas.

Recommendations 10.1 Older people's access to allied health services needs to be increased through the extension of Medicare items and the extension of co-ordinated care and Multipurpose Services

11. DENTAL CARE

One of the worst examples of poor health policy is in divorcing the oral health of individuals from all other aspects of their health care. The greatest deficiency of our national health system is that there is no assistance for low income people to maintain oral health. However, high income earners are receiving public subsidies for dental care through the 30 per cent private health insurance rebate which helps cover the cost of premiums for ancillary cover.

We continue to hear that many older people are missing out on basic dental care throughout Australia and are subject to very long delays in receiving treatment. While there is a lack of good information about waiting times, we hear:

• a number of public dental services have closed off their bookings

• others report waiting times well over 12 months

• treatment is emergency only, impacting on many older people who need dentures or denture repairs.

The Council on the Ageing continues to advocate for Federal Government financial and policy involvement in dental care despite it continued resistance to such involvement. COTA argues that poor dental health can contribute to the deterioration in the overall health of older people that can lead to premature admission to a nursing home or death.

Early intervention for dental problems is important in preventing further deterioration and to encourage preventive dental health practices such as regular and appropriate cleaning.

Many of the older generation have dental health problems as a result of a number of factors:

• the ageing process which results in the wearing down of teeth, fillings and gums

• the loss of most or all natural teeth (edentulism) necessitating dentures due to past dental care practices - this is quite common in people over 65

• heavily filled teeth which require ongoing maintenance and replacement from time to time

COTA considers that there will be ongoing need for public dental health services that ensure that low income people receive a minimal standard of dental health care. COTA does not envisage that there will be any diminution in need for many years into the future. Older people - people over 55 - will make up a very significant proportion of those requiring public dental health services.

Many people will be reaching older age groups with their own teeth rather than dentures.This will have significant implications in the future for the need for good dentistry to maintain those teeth in good working order. This is especially the case if the teeth have been filled as they are most likely to be for the pre-fluoridisation generation (Australian Institute of Health and Welfare (1994) Australia's Health, Australian Institute of Health and Welfare, Canberra, p97).

A national dental health policy is needed. To achieve the aims of the policy, the Commonwealth will need to provide funding for dental care in addition to that already provided by the States and Territories. The national policy must set standards which:

• Focus on preventive dental services including: regular check-ups, fillings and restoration rather than extractions.

• Ensure that treatment is appropriate and timely: swift, remedial action when problems do arise that aim to save teeth rather than extract them

• Ensure that dentures are well-fitting and comfortable;

• Enable the public dental service to contract private dentists or services;

• Ensure that people in rural and remote areas have access to public dental services;

• Ensure that people in institutions including residential aged care have access to dental services when they need them;

• Provide services for special needs groups:

• people on low incomes
• older, frail people
• people with dementia
• people in rural and remote areas
• people in residential aged care

The renegotiation of the Australian Health Care Agreements with the States and Territories in the next 12 months will provide an opportunity to ensure that all levels of Government are contributing to a national dental health scheme.

Recommendation 11.1 Development of a national dental health policy with funding for a national dental health scheme.

12. HEALTH PROMOTION

Public health measures play an important role in promoting many aspects of health status for older people. Older people constitute a population group that have a particular interest in the appropriate application of public health measures. The fifteen leading causes of burden of disease have been identified by the Australian Institute of Health and Welfare (Mathers C, T Vos and C Stevenson et al (1999) The Burden of Disease and Injury in Australia, Australian Institute of Health and Welfare, Canberra). Most of these causes are conditions experienced by older Australians.

The range of public health issues which are of special relevance to older people are very wide and include:-

• mental health, suicide and depression

• male specific health issues

• female specific health issues

• cancer screening

• neurodegenerative disorders

• cardiovascular disease

Public action in all of these areas makes a substantial contribution to the quality of life of older people in terms of the following:

• prevention of health problems;

• appropriate treatment of health problems; and

• support for carers and people affected by health problems.

The great strength of public health is in its focus on prevention and early identification of health problems which is particularly crucial in the case of older people. For example, good nutrition and exercise is a much more cost effective way of dealing with osteoporosis rather than expensive hip replacement and subsequent rehabilitation. In addition such preventive practices mean less social disruption to individuals and their families. There are also examples of imbalances between treatment and prevention such as free treatment for an individual under Medicare for a disease but a cost for a vaccination (as is the case for hepatitis or pneumonia).

COTA is of the view that prevention and health promotion plays a vital part in cost control in the health system. We believe that many common health conditions of older people are preventable and their prevention would mean huge savings to the public purse.

Recommendation 12.1 A fixed proportion of the health budget dedicated to health promotion measures. 12.2 Extension of the National health priority areas to other causes of the burden of disease.

13. MENTAL HEALTH

Many older people suffer from depression and mental illness. Very often the conditions are undiagnosed or incorrectly attributed to old age or dementia. Hence older people are recorded as having the lowest levels of mental illness (Australian Institute of Health and Welfare (2000) Australia's Health, Australian Institute of Health and Welfare, Canberra, p.77). Some studies (see Klinger J (1999) "Suicide Among Seniors",in Australasian Journal on Ageing, Vol 18, No. 3, Council on the Ageing (Australia) Melbourne) show that older people are the highest risk group for suicide but do not receive the publicity of younger age groups. There is a link to the inadequate treatment for psychiatric illness amongst older people who have committed suicide.

In addition, depression is very often linked to other diseases common in old age and can be a result of pain and discomfort.

Older people have not been a group that have been targeted for mental health policies in the past.

Recommendation 13.1 Development of a national mental health strategy for older people.

14. INDIGENOUS HEALTH

According to the Australian Institute of Health and Welfare (Australian Institute of Health and Welfare (1998) Australia's Health, AIHW, Canberra p28), life expectancies for Aboriginal and Torres Strait Islander men and women (living in Western Australia, Northern Territory and South Australia) are 14 to 20 years below those of other Australians.

The AIHW points to the many diseases to which Aboriginal people fall victim, resulting in premature death or disability. These diseases are in the main preventable.

Clearly the factors that contribute to the poor health and reduced life expectancy of older Aboriginal people are very complex and there are many experts in this area who can be consulted by Government.

Improvement in the health status and life expectancy of Aboriginal Australians will only be achieved by an integrated, multi-dimensional approach that incorporates recognition of the cultural values and underpinnings of Aboriginal people themselves.

At a minimum, Aboriginal communities need the following to improve the life expectancy and health status of members:

• adequate, culturally appropriate housing;

• good nutrition;

• clean water supply;

• access to educational opportunities particularly for children and young people;

• adequate income;

• access to good quality and culturally appropriate health and community services.

While a health policy for Aboriginal people must take a broad multi-faceted approach to the task of improving life expectancy and health status, there also needs to be immediate improvements to the services that are available for older Aboriginal Australians.

Service arrangements should reflect the known health needs and deficits of older Aboriginal people. Primary health care services and public health programs should be located wherever possible within or close to Aboriginal communities. Opportunities for participation by members of Aboriginal communities in service planning should ensure that services are culturally appropriate.

Aboriginal health workers should have an important role in the care of older Aboriginal people. There needs to be an expansion of training opportunities in this area.

At the same time, it is important that older Aboriginal people have access to appropriate residential aged care facilities. Facilities such as the Aboriginal Community Elders Services in Melbourne need to be supported and their availability expanded.

Geographically accessible and culturally appropriate health services, community services and residential aged care for older Aboriginal people need to be expanded.

An effective national policy on Aboriginal health must also ensure access of Aboriginal communities to the mainstream services that are available to other Australians. The reality is that many Aboriginal people need to use mainstream services and indeed do use mainstream services where they are available. However, accessibility to services and successful use of services can be impeded where there is lack of cultural awareness and understanding.

Any strategy for improving Aboriginal health and life expectancy must be underpinned by mainstream services with staff trained for working with Aboriginal people or with trained Aboriginal people themselves.

Aboriginal health policy needs to incorporate both specific services run for and by Aboriginal people and mainstream services which are culturally sensitive and provide appropriate services for Aboriginal people.

Aboriginal communities need to have access to mainstream services which are staffed by people who have the cultural awareness skills to ensure that Aboriginal people are able to successfully use the services.

Recommendations 14.1 Strategies to ensure indigenous peoples' access to mainstream health services used by all Australians 14.2 Strategies to develop specific services to meet the special needs of indigenous Australians.

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Copyright © 2001 Council on the Ageing. All rights reserved.
Date: 26 March 2002
Revised:

Council on the Ageing (Australia)
Level 2, 3 Bowen Crescent, Melbourne Vic 3004
Tel (03) 9820 2655 Fax (03) 9820 9886
email cota@cota.org.au
www.cota.org.au