industry & reform
Integration disintegration
When too much assessment for
aged care is not enough.
By Michael Fine
T
here are two simple lessons that
should be part of the induction
briefing of any new minister of
health or aged care in Australia.
1. Integration is not the magic cure for
all problems of service delivery. Poorly
designed integration actually causes
problems rather than fixes them.
2. No-one, especially the Australian
Department of Health, should be allowed
to roll out major changes in the way people
access care before there is conclusive
evidence that the changes proposed have
been scientifically proven to be practical
and effective.
In the middle of January 2020, amid the
catastrophic bushfires that had been going
on for months across the country, just when
every Australian citizen thought things had
got as bad as they could, we learned that
there are plans to abolish the trusted, tried
and tested system of Aged Care Assessment
Teams (ACATs). How? By combining them
with the much less successful and largely
untrusted system of Regional Assessment
Services (RAS) that have been operating
since 2015.
Where were the monster airborne water
bombers when we needed them most?
With the RFS already fully engaged, it
was left to a handful of public-minded
geriatricians and a number of outspoken
state ministers of health to oppose the
initiative as best they could.
Sadly, since then, the confrontation
has gone on unchecked. It appears likely
to continue out of control until further
catastrophes help bring policymakers to
their senses.
No-one could say we were not informed
ahead of time. A discussion paper,
Streamlined Consumer Assessment for
Aged Care, was released by My Aged
Care on 8 December 2018. It detailed
the history of this initiative and its links
to the government’s More Choices for a
Longer Life Package announced in the
2018–19 budget.
Consultations subsequently took place,
with over 200 submissions received before
11 February 2019. Most were later cited
as supportive of the proposal, although
there were a large number of submissions
from CHSP service advocates that were
reported to have called for direct access
to single CHSP services instead of the
time-consuming and uncertain process of
assessment by the RAS.
Yet despite the support the proposal
received from COTA, and from large
residential care and Home Care Package
service provider organisations such as ACSA
and LASA, it has not been advanced to
clinical trials which could test how the new
approach will work.
The success of ACATs over the past
three decades is founded on years of
demonstration trials that followed the work
of famous Newcastle-based geriatrician
Dick Gibson and his colleagues who
pioneered the world-beating approach.
Subsequent research has repeatedly
shown the value of the deliberately
designed independence of the ACAT
teams from the service provision system.
Integrating them with RAS services and
putting them out to tender threatens to
undermine their professional autonomy
and destroy their independence.
Assessment, as it is currently
implemented, is a one-off rationing process
that takes place at the point of entry to the
service system. Its great value, however, is
as an ongoing advisory process that takes
place on a regular, if possible daily, basis,
adjusting the assistance and care provided
to the individual’s changing needs.
Such a process will often free up
resources, as many people enter the
aged care system with urgent needs but
gradually recover to an extent, sometimes
regaining all their capabilities to remain
independent. Without ongoing expert
assessment, these resources can’t come
free, and the system quickly becomes
clogged up with new referrals and long
waiting lists.
To achieve a single assessment
process in the Australian system, a much
simpler solution would be to close the
RAS services. This would leave ACAT
assessments in place for the relatively
expensive Home Care Package and
Residential Care programs, but remove it
for the low-cost CHSP, which on average
cost the government just $55 per client per
week in 2018–19. This would free up many
RAS staff to be deployed as skilled care
workers and assessors within home support
services without costing the government a
cent. And, as if by magic, we would have a
simplified, single assessment service again.
Imagine a comparative trial over the next
year or so, where some regions received
the well-proven single ACAT service with
direct access to clients seeking support at
home from CHSP services. Other regions
would receive the proposed integrated
single assessment service. In the first trial
model, all CHSP services would receive
extra staff (those employed in the current
RAS agencies), while in the others, there
would be an integrated assessment for all
service applicants, no matter how modest
their needs were.
Which areas do you think would deliver
the shortest waiting times for service
access? Which trials would deliver the
best reduction in the huge wait for Home
Care Packages?
Or, we could continue on the current
pathway, where scientific evidence and
demonstration of success are deemed
irrelevant. ■
Michael Fine is honorary professor of
sociology at Macquarie University
agedcareinsite.com.au 13