Aged Care Insite Issue 111 | Feb-March 2019 | Seite 10

industry & reform
Three cheers for
three tiers
In aged care, one size
does not fit all.
By Michael Fine
H
ere’s a simple idea for the Royal Commission into Aged
Care Quality and Safety.
Let’s try and assist as many older people as possible to
stay at home to receive their care.
To help this along, we should try to make access to basic
support services simple and easy, not difficult. Let these basic
services do what they can to enable and re-able people to remain
at home. And if they can’t, consumers can be referred on to
receive more complex care at home, or in very complex cases, to
residential care services.
Instead of trying to force the entire aged care system in Australia
into a single pathway, as the Aged Care Roadmap attempts to
do, perhaps we should consider the merits of a more cleverly
differentiated approach.
After all, it is only through pursuing the simplification that a
single unified system entails, that we have got ourselves into a
mess involving waiting lists of 12 months and more for a home
care service, and long waiting times for assessment that hold up
any access to support provided at home.
The Roadmap, published in 2016, is clear in that it seeks a simple,
single aged care system, spelling out its goal of producing what it
describes as “a single aged care and support system that is market
based and consumer driven, with access based on assessed need”.
This, in turn, requires appropriate assessment procedures,
and so the Roadmap outlines the goal of introducing “a single
government operated assessment process”.
You’ll note how this single system is exactly the opposite
of the systems logic we employ in healthcare. In line with the
recommendations of the World Health Organization, healthcare in
Australia and elsewhere is clearly divided into three tiers.
Imagine the difficulty and cost if every time you needed to
use primary care – to visit the GP or the dentist for example
– you first had to go through a single government-operated
assessment process.
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The logic is to deal with the greatest number of problems
possible at the most basic, cheapest, most cost-effective level.
That’s why it is called primary care. This enables the much more
expensive upper tiers of the system to provide more intensive
and specialised professional support to much reduced numbers
of people.
The referral and funding process in the healthcare system
continues to be contentious. Nevertheless, one point of
agreement is that access to the second and third tiers needs to be
on the basis of careful referral and assessment, a process based on
referrals from GPs and other primary care practitioners.
Using our imagination, we can take a quick tour of other
comparable areas of public responsibility. One example that
springs to mind is that of the law. Of course, there is only one
set of laws and these apply, more or less fairly, to everyone in
the country. But the mechanisms for applying that law are quite
complex and differentiated.
Think of the problems that would be involved if every ‘offence’ was
treated as requiring adjudication in a court. Of course, if you’d like to
dispute a traffic fine or other minor punishment, you can go to court.
Similarly, magistrates deal with many of the more complex lower-
level legal issues, restricting the use of full trials with judges and juries
to cases likely to result in serious criminal punishments.
Now imagine that older people who needed advice or some
basic support were simply able to approach their local Home
Support Services and ask for help. If they needed more than that
service could provide, they could be referred on, and perhaps
wisely, receive a serious and professional assessment.
The number requiring assessment would be considerably less
than the number requiring one now. I suspect we’d see much
reduced waiting lists for home care packages.
Amazing, isn’t it, how some of the elements remind you of the
system we had just a couple of years ago, before waiting lists blew
out and support became difficult to access, as it is today?
What we need is a more fundamental rethink that will enable the
Home Support Program to become a full primary care program.
We need to develop staff skills and careers and back them with
a different funding system to the competitive assessment and
activity-based fee system proposed. If we keep going to the
destination set out in the Roadmap, we will surely drive both
the waiting lists and the cost of aged care up, not down. Long
waiting lists for home support will also have the very predictable
consequence of increasing admissions to residential care.  ■
Michael Fine is an honorary professor in Macquarie University’s
Department of Sociology.