CHAIR —I welcome the representatives of Aged Care Assessment Service Victoria to the table. I remind you that the evidence you give at this public hearing is considered to be part of the proceedings of the parliament. I therefore remind you that any attempt to mislead the committee is a very serious matter and could amount to a contempt of the parliament. Aged Care Assessment Service has made a submission to the inquiry, and copies are available from the committee secretariat. Would you like to make an opening statement before I invite members to proceed with questions?

Mrs Harvey —Thank you. ACAS Victoria is a state-wide group of ACAS managers who meet monthly to share information and discuss areas of concern that are emerging in the clinical and operational fields. Today we welcome the opportunity to meet with this committee, and thank you for the invitation to attend. Aged care assessment teams, or services as they are known in Victoria, have a core objective which is to `comprehensively assess the needs of frail older people and facilitate access to available care services appropriate to their needs'. This is taken directly from the ACAT operational guidelines of 2002. Regardless of the state or territory ACAT operates in, this objective remains a constant guiding mission for the program. In undertaking this objective, ACATs are in a core position to observe and participate in the service system for older people and therefore we feel we are well placed to comment on the issues in aged care that exist today.

In viewing the Hansard reports that record the submissions made by other organisations over 2003 to this committee, it became apparent that ACATs across Australia have an interface with most of the previous groups interviewed. As an ACAT service we are constantly dealing with consumers, carers, service providers, residential facilities, hospitals, people from ethnic communities, Indigenous communities, veterans, medical practitioners and many other groups in the community.

ACATs service both metropolitan and rural areas and while there are differing issues between city and country there are also some common themes that become apparent through the discussions held at ACAS Victoria. In our submission we have highlighted some of the areas of concern. These can be broadly split into three areas. Firstly, there are the issues relating to residential care, and these include the availability of beds, ageing in place, staffing concerns and the lack of appropriate respite care for community dwelling care recipients. Also, the inconsistency between the ACAT assessment and the residential classification scale, known as the RCS, is an area that causes concern for both ACAT and residential care providers.

Second is the issue of the treatment of older people in the hospital sector. Often a hospital is not an appropriate place to address an older person's issues; however, currently there is little choice of alternative care to address health issues for this group of people. Access to acute beds and then at a later point the move from acute care to permanent residential care is a contentious issue due to the high cost incurred when a person is waiting for residential care in the acute care sector.

Finally, the amount of service provision an older person can access while still living in their local community is a growing area of concern. With rising costs all services are having to rationalise what they can provide. This can be very limiting and as a result some people will enter residential care earlier than perhaps they would have if the service system were able to meet their needs at home. Resourcing is also an issue for ACATs. With rising staff and operational costs, the ability of an ACAT team to meet targets can at times be exceedingly difficult.

In conclusion, ACAS Victoria, representing individual teams across the state, remains highly committed to working with all groups within the community to meet their needs and to further develop close working relationships that enhance the consumers' ability to access appropriate services in a timely manner.

CHAIR —Thank you. In your submission you said there is a disparity between the RCS classification and your own classification. How will you address that? Do you have any proposals for that?

Mrs Harvey —The disparity lies around a fundamental difference between the two things. In an ACAT assessment we are being asked to identify the level of care someone is at. The RCS assessment is around the funding tool for the facility. The two really do not marry up in any way, shape or form, so it causes great conflict. We might think someone is at a low level of care but a facility might think they are higher on the RCS. There are dollars attached to that so there is some friction.

CHAIR —You have also addressed the staffing issue. Have you had an opportunity to make a submission to the joint review that is being done at the moment by Kevin Andrews and Brendan Nelson? They have announced that they will be looking at staffing in aged care up to 2010.

Mrs Harvey —Not at this point.

Ms HALL —I will move on from where Andrew started. There is an across-the-board shortage of staffing, and staffing specifically for your teams throughout the state. What are the specific areas in which you have staffing shortages?

Ms Houghton —I think certain teams have problems with recruiting. I think, particularly, some rural teams have difficulty in recruiting staff that we ideally need—that is, staff who have adequate experience working in both the health and the community sector. But I think we are also referring to the staffing concerns with residential care facilities.

Ms HALL —I was coming to that as well. I just want to concentrate on your teams. Do you have any specific disciplines?

Ms O'Donnell —The rural area needs geriatricians—there is a real shortage. We do not have the support of a geriatrician in our team, so we rely just on the allied health professions. Again, ACATs have allied health professionals and they are in shortage in all areas of health care. Staff are difficult to attract rurally, particularly senior staff who have extensive experience across the sector, in both the acute and community areas. It is a problem. When the city is short of allied health people, the rural areas are even shorter.

Ms HALL —I will go down a level. You were referring to shortages in facilities. Once again, can you go through the areas where you perceive these shortages to be? Registered nurses?

Ms Houghton —I think that generally the facilities have difficulty in recruiting nurses. I think it is not a glamorous area for nurses. Now that the hospital sector realise that they have to offer nurses more, I think we are competing against their recruitment campaigns. So, the residential care sector is competing against the hospital sector.

Ms HALL —Is there a wage disparity?

Ms Houghton —Yes. I think that is another issue.

Ms HALL —Assistants in nursing—are there shortages there, too?

Ms Houghton —Yes, because, again, with personal care attendants the community sector has grown enormously. That sector is competing with the residential care sector. Generally it is a very poorly paid area, so it is hard to recruit people anywhere. I think we are really noticing that. You hear the local councils talking about their difficulty in recruiting, and you know that the facilities are having difficulty, too.

Ms HALL —The other area is the community sector providing the services in the community. You have already identified that there is a shortage. Have you any solutions?

Ms Houghton —There is the obvious one, I think, of more resources in the form of funding.

Ms HALL —What about the training of suitable staff? Have you looked at any training packages?

Mrs Thorn —I think training needs to go right across the board. We need to start with doctors in their tertiary training. They need to understand the special needs of the older person, so that if they are attending an aged care facility, they are able to provide quality care planning. Currently, under their funding, there is no incentive for them to participate in care planning. Allied health professionals, in their training, need to understand better that there is a very big difference between the acute focused allied health professional and the aged care focused person. It is the same with nursing. It is a special person who understands the needs of the older person. That is where a lot of our problems happen in the acute hospital, as well.

CHAIR —For your service, do you have any idea how many clients you would assess in a year?

Ms Houghton —We have targets that we have to meet.

Mrs Harvey —For example, in the Kingston ACAS we would assess 3,000 to 3[half ] thousand clients in a year.

CHAIR —I see.

Mrs Harvey —That is a mixture of hospital assessments and community based assessments.

CHAIR —In Wangaratta?

Ms O'Donnell —In Wangaratta, we do about 1,300 in the eastern, or Hume, area. Most of ours are done in the community. In fact, there has been a trend towards more community based assessment to ensure that people are actually seen in their normal situation. They are more likely to have community based recommendations if they are in the community sector as opposed to when they are assessed within the hospital situation. ACATs have tended to push towards more community based assessment of the elderly.

CHAIR —Are you able to tailor to the individual client whether they end up in the community or residential area?

Ms O'Donnell —Yes, that is the purpose of an ACAT assessment—to have an individual comprehensive assessment to determine their needs and, of course, their desires as well. The family would also be considered. We find that most people wish to stay in the community. We then have to try and access services for them wherever possible to enable that to happen.

CHAIR —Would you work quite closely with a social worker in doing that?

Ms O'Donnell —We would work with a number of other service providers, depending on what the care plan was actually looking for. As the chair said before, we interact with a number of different service providers in trying to meet the needs of the person we are assessing.

CHAIR —Given that it seems there is some unmet need, waiting lists and so on, do you find it hard to tailor what would be best for a client?

Ms O'Donnell —Yes. You have the care plan you would like in an ideal world, then you might have to compromise with what is available out there. At the moment, for instance, 150 people in our area are waiting for a community aged care package. So while it might be suitable for a lot of people, you know the wait is going to be too long, so you might have to do something in between.

CHAIR —If someone is going to receive community care, how do you decide whether they get HACC or community aged care? Is it basically the same level of service in your community?

Ms O'Donnell —That would be based on needs and what informal support was there, such as the living arrangements of the person. You would also consider what was available—and you have some understanding of what is available. It might be that HACC is only one hour a fortnight and that may not be appropriate for that person. So you need to tap into whatever services you can find. You actually have to be quite creative sometimes, as a worker, in seeking out things.

Ms HALL —I was going to ask you about respite care, but I will go back to that. I will follow on with something that is a continuation. What sort of waiting list do you have?

Mrs Harvey —At the Kingston ACAS we are operating at the moment probably on anywhere from a five- to eight-week wait for a community assessment. For a hospital assessment, we are meeting our target of a one- to two-day turnaround time.

Ms HALL —Once an assessment is completed, what is the period before a person gets either a placement in a community program or a facility?

Mrs Thorn —In our region it is about two weeks before HACC services can commence and about two years for a community aged care package. We have another problem now with community aged care packages, and it is really making us sit back and think. Once upon a time you had to anticipate where you thought the person might be in 12 months time, given that the approval was for 12 months. Do you put them on the waiting list for a package just in case or do you see that there may be a need in less time than that? We almost run an A and a B list. Everybody starts on one list and then, as the situation deteriorates or the need becomes greater, we will start lobbying and put them on the other list. But there are now issues around full cost recovery if they have gone on to a community aged care package for day centre. Because of the state and Commonwealth differences with the aids and equipment program, the old PADP, they are no longer able to receive assistance through PADP.

Ms HALL —Could you explain that a little more to me? I highlighted PADP in your submission. What is the problem there?

Mrs Thorn —They are no longer eligible to receive aids and appliances through the program.

Ms HALL —Why? What are the criteria these days?

Mrs Thorn —It is because of Commonwealth-state differences and agreements. I think they call it double-dipping. Where I usually have at least a 12-month wait, we can get the early things that one might need. There might be some smaller home modifications: an over-toilet frame, a wheelie walker and continence aids. But once you come onto a package—and if, as in Kingston, there is an eight-week wait for a package—you do not have time, because you can be waiting a good six months for PADP approval of your aids but then you are no longer eligible to receive those aids. So the person has to pay for them. As they age in place in their homes, their needs become greater as well. They might need a bathroom modification or a ramp; they might have ongoing continence problems. So you really start to wonder what are the benefits. Often it is only the case management that is the benefit of the community aged care package. Another issue is that all the providers are really operating slightly differently.

Ms HALL —You have raised some really good points there.

Mrs Harvey —Across metropolitan Melbourne there are different waiting times for a community aged care package, because certainly in my district, in the southern region, we can find a package for someone with relative ease. We assess them and a package is identified as the required outcome. We can find a package provider fairly easily, but that is primarily due to the huge growth in providers in our district. Now, as those places are being filled up, I anticipate that it will start stretching out a bit more. Certainly, access to the package is not a problem for us, but that creates a problem in terms of the equipment provision. Because we can get them on early, we do not have that lag time to go through the system a different way to get them the equipment they need. So that causes a dilemma for the provider. Because they—either the client or the provider—cannot afford to pay for that themselves, what do you do about equipment? It becomes a big issue to help support people at home.

Ms HALL —With the community aged care packages, do you find that there is a reluctance by some providers to provide services in particular areas?

Ms Houghton —Yes. Something that has been raised with our state-wide group is that some providers might have a designated catchment but they are reluctant to go to the outermost reaches of that catchment because they have issues of having the staff who are able to do that in the time frames that they need to. We can find that a whole geographical catchment is not necessarily covered.

Ms HALL —So do you think that the guidelines need to be reviewed to ensure that there is equity in the delivery of and access to the services?

Ms Houghton —Yes. We think everybody should be able to access them, regardless of where they live.

Ms O'Donnell —Also, there should be some standards of practice around case management and what that means. Because many providers operate differently and their interpretation of the guidelines can be different from another provider's, inconsistencies are practised in the case management service.

Ms HALL —So there should be a benchmark of care?

Ms O'Donnell —Yes, a benchmark of care.

Ms HALL —Or accreditation? Maybe a benchmark of care would be the way to go.

Ms O'Donnell —Because of the huge length of time in rural areas, we have been trying to move away and trying to get people a bit more upstream. The providers have been saying to us that they have been getting people who are far too needy, essentially, and the package cannot support them. So we have rejigged everything to try to catch people more upstream with some basic care to enable them to stay, rather than use the package as crisis management where the needs are very high and it is not sustainable for the package over the longer term. Revisiting why the packages were introduced—to keep people at home rather than prop up crisis management. That is not to say that crisis management is not an issue in itself, but CACPs were not set up to do that.

Ms Houghton —I think that goes back to the waiting times. There is a difference in waiting times across the state, but even for my team in my own catchment there are four local government areas and in two of them we can access HACC services and CACPs fairly quickly—the CACPs are attached to the local government—but in the other two areas the waiting time for basic home care services is up to eight months. That is what we are looking at as a preventive service to keep somebody going so that they do not deteriorate. Therefore you might be looking at CACPs, because you know you have a chance of getting CACPs quicker than HACC. It is around the wrong way. CACPs should come in when HACC can no longer meet their needs.

Ms HALL —So you are suggesting a streamlining of the services?

Ms Houghton —Yes.

Ms HALL —That is important information for us.

Ms O'Donnell —And trying to get a bit more upstream, with basic HACC earlier and getting in earlier rather than further downstream when people are really in high need.

Ms HALL —So establishment of a continuum of care?

Ms O'Donnell —Yes.

Ms HALL —That is good.

CHAIR —You assess people for the Linkages program, HACC, community aged care packages, residential facilities and ageing in place?

Mrs Harvey —Yes.

CHAIR —So it is everything. It has been put to us that there is unnecessary duplication in some of these programs. Do you see a difference between these programs?

Ms Houghton —There is a difference between the programs. There is a bit of duplication of assessment processes too, and I think that is a concern. Each of those services has its own requirements to meet its occupational health and safety issues. We can go in and do a comprehensive assessment and refer on to them. They will then have to go through an assessment process which has a certain focus that we do not necessarily look at. It also perhaps repeats some of the things we have considered. It is going to take some time before we trust each other's assessments a bit more.

CHAIR —Is it possible with ageing in place that you do have a continuum of care? Isn't that the principle behind ageing in place?

Ms Houghton —The term `ageing in place' is restricted to residential care but the concept of continuum of care is very important.

Mrs Thorn —So if we were referring from our service to the council for showering assistance, they would go back to the RDNS and have them do a showering assessment and ensure that all the OH&S requirements were met before the council would continue to shower.

Ms HALL —There are some real issues there, aren't there?

Ms O'Donnell —There are issues for the client.

Mrs Thorn —Definitely.

Ms O'Donnell —The client focus, the care approach, seeing different people all the time, asking them similar questions and coming into the home are issues.

Mrs MAY —Being assessed for a certain service and then having someone else coming in asking the same questions for the same service must be very upsetting particularly for the elderly and their families.

Mrs Harvey —It is certainly not uncommon for us to be told by a client or a family member, `I have already answered this three times. Why do I have to tell you?' People can get particularly distressed by that. It is not every family but we would all have had people commenting to us, `I saw someone only last week and I answered these questions.'

Mrs MAY —Is that then delaying the service being delivered too while these processes are being redone?

Mrs Thorn —Victoria has primary care partnerships and within our region, for example, we will be using a tool called the SCT, which is a service coordination tool. We will be sending that same referral information to the Royal District Nursing Service or to HACC services so that a lot of that preliminary data is not being asked for again. That facilitates that and then you can build on the referrals that have been made out of your assessment and, hopefully, that will reduce some of that duplication. That has not come in formally yet.

Ms HALL —The information you have given us is important and it should be on the formal record as part of the workings of parliament. Even from the accounting point of view, it seems to me that it would be much more cost effective if things could be streamlined and the duplication were stopped.

Mrs Thorn —Baptist Community Care in their submission referred to having a central network, a continuum of care, and I found that concept quite interesting.

Ms HALL —Respite care was the next thing that I wanted to talk to you about. How easy is it to access? Do you have waiting lists? How easy is it to get somebody into a high-care bed for respite care?

Ms Houghton —In our region it is impossible. The number of respite beds available on the ground today is very limited and to try to get someone into planned respite well down the track is incredibly difficult. For emergency respite it is even worse. There are fewer and fewer beds available and it is something we have grave concern about.

Ms HALL —Does the way those beds are funded have any relationship to the fact that respite care is hard to get?

Ms Houghton —The facilities have indicated that there is not enough incentive for them to offer respite, particularly high care. They have long waiting lists for people to come in permanently. So, with the turnaround with respite, they need more of a financial incentive to take on that extra load.

Mrs Harvey —Providers also say that the paperwork involved in bringing someone in for respite care for two weeks is enormous, and they are not prepared now to do that.

Mrs Thorn —The facilities are not funded if the bed is not filled. We have about 2,500 respite bed days in the north-east region and we use about 500 of those a year. The only ones that are being fully utilised are being managed through the care and respite centre, where they do a lot of the paperwork and provide extra dollars for settling in and so on, so that extra staff can come in at the times when residents are coming in and going. If the bed is not filled for some reason, the facility does not miss out.

Ms HALL —That is the issue I was hoping to pick up.

Mrs Thorn —The other issue is that a lot of the people going into high care respite are in fact above an RCS3 and the funding does not really match their care requirements.

Ms CORCORAN —I want to go back a step. I have forgotten whether there are 50 high care places or 50 low care places. There is a 50-40-10 distribution—in the home, in low care and in high care. Is that ratio about right or does it need to be rejigged?

Mrs Thorn —From our perspective, it needs to be rejigged. We have a number of multi-tier facilities, where we have independent living units, low level care and high level care, and they tend to feed in from within their facility. They call it `ageing in place' within their community. It means that very few people get into the high care beds from within that. We have an ethno-specific facility that has 90 hostel beds and 30 nursing home beds. Fifty-four of the residents in the low care section are actually high care residents. The expectation for the 90 people is that they will all feed in to the 30 beds, and there just are not enough beds. They are fairly demanding residents as well.

Ms CORCORAN —It needs to be pushed along to more high care beds and less—

Mrs Thorn —Very much so.

Ms CORCORAN —What about the 50-40-10 bit? Are there more home care CACPs places than—

Mrs Harvey —I think there is a shift these days. Whereas once someone would have gone into a hostel and had a natural progression through to high level care ultimately, those people are not necessarily going into hostel care at all; they are staying at home. I think there is a need for more community type care, like the package—

Ms CORCORAN —So move the 10 up to 20 or 30 perhaps?

Mrs Harvey —And incorporate some of the edge type packages that provide a higher level of care at home. Plus there is also a need for more high level care because people are bypassing the hostel level and going straight to high level care. There has been a change in focus because people ultimately want to stay at home until the absolute end, until they have to move on, and that often means high level care at the end of that.

Ms O'Donnell —We are supporting people in the community at a much higher levels of care than we have, and it is what people want, if we can do it.

Ms CORCORAN —Could I go back to an earlier question and the point you raised about the difficulty between the RCS funding model and your own assessment. You explained the difference and where the conflict is. Do you have an idea of what the solution might be?

Mrs Harvey —The conflict often comes in for us at the point where they have been in a low level facility, and now the provider is thinking that they require a higher level of care and they want a reclassification to high level care. On our assessment we say, `We still think that they require low,' and they say, `On the RCS we feel that we should be able to claim more.' It is something that, as a group, we have discussed many times. I think that having us come in to make that decision midway through their life in that facility is perhaps not the best way of dealing with it. There should be some process in place to allow the facility to make that judgment based on their funding arrangement, and perhaps we come in at a later point when they can no longer keep that person in that facility and they need moving on to a traditional nursing home. If that money issue were out of the way they could then call on us for a more consultative type approach, when they are just having issues around managing people and want our advice.

Ms O'Donnell —They rightly feel a little bit put out, because they actually manage that person 24 hours a day and we come in for a one-hour assessment and say we disagree with them. It sometimes opens up a conflict because they are seeing this person more often. It is a conflict over money, essentially. We would like to keep the funding issue separate. We would prefer to have our skills used to manage care plans and to look at more restorative options for people, rather than fighting over the funding.

Ms CORCORAN —I want to ask about the concept of ageing in place. I am not talking about ageing in place at home; I am talking about the ageing in place that—without wanting to put it down—is flavour of the month, and that is ageing in place once you are in residential care. In my community there have been conflicting comments: some people think it is really great; others do not think it is so good at all. Do you have any comment to make on the concept?

Ms Houghton —I think the concept is good: to have people stay in one spot for as long as possible. So the basic idea behind it is fine, but you then have to be able to increase the care provided to that person more than what the low care facilities are funded for. It is much better for people not to have to move; and it could be that if they can age in place to a greater extent that what is funded for now, perhaps they will never get to that nursing home stage and they will die in the hostel. That is preferable for them, but it requires the facility to be able to do it.

Mrs Harvey —My concern would be that a lot of people age in place to a certain point, which would be when the staff can no longer manage that person because of very high care needs—two-person transfer case, doubly incontinent—and at that point they will often say to families: `We can't look after your mother or father. You'll need to move them to a nursing home.' That happens at a very difficult time for the individual: they are very frail in health and all of a sudden they have to uproot themselves from the place where they have lived for a number of years and move on. So whilst ageing in place as a principle is good, because it does not carry through from admission to death it means there is still a move for some people at a later date, which is very disruptive at a critical time in their life. We are seeing the growth of facilities being built now with a mixture of high and low beds so that they can manage to age people all the way through the spectrum, but that is just starting to emerge as new buildings are being built.

Ms CORCORAN —Some of the providers in my electorate are making the comment that the residents do not like ageing in place, that they do not want to be in there with all these old people. Is that an attitude that you have picked up at all?

Mrs Harvey —It is not something that has been said to me. But I could imagine that fitter, more active people with fewer care needs may well dislike being grouped with others who are incredibly frail and may perhaps feel that they are in the wrong place.

Ms CORCORAN —Or with those with dementia?

Mrs Harvey —Yes.

Ms O'Donnell —It would depend on the facility and how they manage ageing in place. We are finding an enormous variation among facilities as to how they do it. Some do it much better than others; others do not even try to do it. In rural areas it is a good concept because people can stay in the community where they have lived all their lives and not have to move to a high care facility a long way away, where their family members cannot visit them because there is no transport. It has appeal in rural areas and there seems to be a bit more uptake of it there. But it is problematic when people have increased needs and the staff do not have the skills to manage them.

Mrs Harvey —There are also some issues around security of tenure that emerge when someone who is ageing in place in a facility goes into acute care because of an episode of ill health and the facility uses that time to make the decision that they do not want to have them back, that it is time for them to move on. That seems to be fairly commonplace. We see that when we are doing the assessments at the hospital end. People have been ageing in place and all of a sudden they are not wanted back. I know Residential Care Rights have had plenty of involvement with that. It is an issue that acute care often precipitates the transition to a nursing home.

Ms Houghton —ACAS are often asked to be involved in that dispute point, when the facility does not really want them back because they have a duty of care issue, the hospital wants to get them out and the family do not want them to move. Often we get called in at that point to try and help sort it out.

Mrs Thorn —Could I add that a lot of it in fact goes back to the planning around the time that we do the high-care assessment. We encourage families and the facilities that they are living in at that time by saying, `You are not really there for life.' A lot goes back to the resident's agreement, what they have signed in the beginning and what their security of tenure is. At that time, the family needs to start looking at nursing homes and start waitlisting at nursing homes. If they are lucky, they won't ever need it and the facility can always say, `It's okay. We are managing your mother okay at the minute.' Alternatively, if a vacancy does come up and they are not managing, then that preparatory work has been done.

Once upon a time as ACASs, we facilitated a lot of direct admissions into nursing homes. We are finding now that when we do the ageing in place assessments, we do not really know what is happening out there. If the facility is tardy or the family is tardy, we are not a case management service but we do need to keep in there until that next stage is really mapped out for them so that they can then sit back, hopefully, and the person can stay on there. If it is not organised or planned, then you have the crisis where they turn up in the public hospitals and so on.

Mrs Harvey —There would be some facilities that would take a dim view of us actually going down that path with the family and recommending that they start forward planning. They would find that quite affronting in terms of their ability to manage that person. It is a very fine line that you walk.

Mrs MAY —In your submission you made a comment about the accreditation system for nursing homes; you felt that it was just another documentation procedure, and it was not actually delivering the high care that we were looking for. Would you like to make a comment on that?

Ms Houghton —I think that was around the time of the first accreditation process for facilities. It was an enormous exercise for those facilities to get all their paperwork up to scratch. That is a good thing because that is a process of being accountable, but I think it really was at the cost of direct care time of the residents. It was an issue and it is an ongoing issue now too. Generally, the facilities find the amount of accountability with paperwork so onerous that it really is limiting direct hands on care time.

Mrs MAY —On the other side, would you see accreditation as bringing some of these nursing homes up to standard, particularly in the care that they deliver? I think we have all seen proof of that out there. Some of my nursing homes have said to me that the initial accreditation process was onerous. It was a huge burden. It took a lot of time and a lot of hours. Now that they have done it the first time, if they have their three-year accreditation, they know on an ongoing basis what is expected next time. Wouldn't you see that as being supportive of the industry which gives them a big tick if they get that?

Ms Houghton —I think you are right that it will get better, inasmuch as it is an ongoing process and it will not be such a huge effort next time. Generally, even day to day, they are feeling that what is required for keeping up to scratch with the accreditation process is an onerous paperwork exercise.

Mrs MAY —I want to ask you about your relationship in Victoria. We heard from the local government association this morning about their role in delivering services in aged care—something which is very foreign to me because in Queensland it just does not happen. I wondered about your relationship with local government in identifying where service needs are falling down or where there are shortages. Do you work closely with them? Do you have any input at that level?

Ms O'Donnell —In the rural sector, we actually have quite close links with local government. We work closely on an individual client basis, but we also review the service system together and highlight areas of need. We do have strong ties with them. They, like us, are suffering from not having enough HACC dollars to actually deliver on the services that we would like. My sense, rurally, is that some of the local governments are thinking seriously about whether HACC is their core business because of the amount of money they are having to use to support the work.

I think the HACC system is extremely stretched. A lot of that has to do with the fact that a lot of money has gone to subacute and also into moving people quickly from hospital out into the community without dollars being transferred into the community sector to support that work. HACC has been asked to now prevent hospital admission through their work. We used to simply have inappropriate residential care admission but we are now being asked to prevent acute admission without any extra dollars. Our brief has grown and the dollars that are being saved in the acute sector are not being transferred into the community sector to support that work.

Mrs Harvey —In terms of the relationship between ACAS and local government, we would all have fairly active involvement in local government circles in relation to talking about the issues on the ground. Often local government comes to us about issues or we may go to them. For every ACAS in the state, I can say that we would have very good interface with them. However, there are issues which we cannot do much to help with. As Gail said, it all comes down to a funding issue. I have good working relationships with local government in my area.

Ms Houghton —And they are critical players in the service system. People pay their rates and they expect something from their local council. It is a connection that makes sense to the older client group.

Mrs MAY —We have just touched on funding again and that issue has been raised this morning. In your submission you talk about clients receiving a lower level of care. This all comes back to funding dollars. We heard this morning that the state can put a dollar value on a service and local government can put a different dollar value on that service. Do you feel that the funding is not keeping up with the cost of the services that are being delivered into the community?

Mrs Harvey —It is a feeling.

Mrs MAY —So that is definitely the problem?

Mrs Harvey —Yes.

Mrs MAY —So it is the cost of the service delivery—

Ms O'Donnell —And the demand. There is increasing demand for services and there is the cost of those services. There are two issues.

Mrs MAY —Thank you.

Ms HALL —In your submission you talk about placement agencies. I am not familiar with them in my area. Could you tell me a bit more about them?

Mrs Harvey —There has been a growth of private groups in Victoria which are there to help facilitate other institutions or individuals in the placement process once a level of care has been determined. For example, you may have a family with a mother who needs nursing home care and they will contract to a private placement person, for which you pay a fee, to help them find the appropriate accommodation for their elderly care recipient. Likewise, hospitals will sometimes employ placement officers to help facilitate the movement outwards from hospital to an appropriate nursing home facility and the fees for that can vary from $500 to $1,000 per placement. There are certainly a number of these agencies around.

Ms HALL —I can understand hospitals employing someone to do it because that can be streamlining between the hospital and the facility.

Mrs Thorn —Some of our hospital patients have extremely complex medical needs, for example, tracheostomies and so on. We had one lady who had a multitude of problems, including obesity, and the hospital social work staff had been unable to place her over a period of time. As an experiment, the hospital employed a placement agency to see whether they were able to do any better and they were not; they still could not come up with a place. The facilities just were not interested in the people with really complex care needs.

Ms HALL —That is a bit of a worry if that is an indication of the future. There will be agencies out there that will not facilitate a quicker placement and they will not be able to get people with more difficult problems into facilities, but they will be charging families for that. Do they still take a fee if they do not find a placement?

Mrs Harvey —Basically.

Ms HALL —That is something we need to look at.

Mrs Harvey —There are some other issues around that. When the institution is employing this type of person, their parameter around it is to find a place—end of story. So there have been instances where someone may have been placed in Williamstown but they live in Black Rock and their elderly carer cannot get to the facility to look after their partner. They only measure success by placement, not necessarily by a placement in a geographic area that is appropriate for the family. When the family are in control of it, they can put more parameters around it in terms of location and size and what they are looking for, but it is a huge growth area.

Ms Houghton —I think there is a market for this sort of service because we have busy families and they want someone else to do some of the legwork and perhaps give them a shortlist. We are concerned that people see a facility before they actually put their name down on the waiting list. There have been examples where they have said okay to something they have not actually seen and when the offer comes they turn it down because that is the first time they actually walk through the door and have a look at it, so there is that concern. As I was saying, I think there is a market for it, but it is a deregulated system at the moment and I think there needs to be a lot of care because people are very vulnerable at that point.

CHAIR —I think you are saying there is nothing wrong with placement agencies per se; it is just that they should operate by some sort of code of conduct.

Ms Houghton —And also by some knowledge base too. They need to know enough about the aged care world so that they know what the client care needs are or work with us to do that.

Ms HALL —So there needs to be accreditation and some guidelines put in place and some control of placement agencies—do you agree with that?

Mrs Harvey —From a social point of view I have a problem with it because my observation over the years has been that families need to work through a variety of issues when they are looking at permanent residential care for someone that they have been caring for. They need a lot of counselling and support through that process. By bypassing a system I think that some families never get a chance to work through those complex issues, and when that person is in placement that is when the conflicts start occurring.

Mr ANTHONY SMITH —So they only postpone the problems.

Mrs Harvey —Yes. There is a place to be dealing with that grief and loss and moving on issues, and sometimes I think in a private placement in a way it gets bypassed. I do not think that is healthy.

Ms O'Donnell —I think the point Deb is making is that it becomes a business transaction. Care of the elderly is not about business transactions, so we need to be very careful about those types of situations.

Mr ANTHONY SMITH —In a general sense you have raised a number of issues, but ours is a long-term inquiry, and I think we all agree that with an ageing population some of these are inevitable. I am wondering, from your standpoint and in a general sense, whether you think anyone overseas does it or certain aspects of it better. Most democratic countries are facing the sorts of challenges we are talking about. Are you aware of any of those, whether they are in the UK, Europe or the US? Although there is a number of challenges to overcome, a lot of the feedback I still get in the general area is that we are doing it better than other countries. I am wondering whether you have a view on that.

Ms O'Donnell —My response to that would be from my reading, which is that those countries that actually take on a social policy approach to ageing have a far broader approach to it and they seem to be able to come up with more innovative and more satisfactory answers to the situation.

Mr ANTHONY SMITH —Which countries would they be?

Ms O'Donnell —Some of the European countries take an approach as to housing. If we are going to move towards more community care options, then it is not just about services; it is also about housing and communities that are appropriate for ageing people, ones that allow people to age within their community, and access not just to their own home but to community services and community buildings. It is about that broader social look at how we want people to age and where people want to be, and it is not just confined to residential care. So I would be hoping that we would look at and have some sort of statement in the social policy area that matches the needs of the aged. It is not just about health and ageing; it is about all the other parts of it too.

Mr ANTHONY SMITH —This inquiry, as you know, is to look to the next 40 years. I am particularly interested. You work in the area. Everyone picks up anecdotes and views, but perhaps there is something particular that you have come across that you think is done better overseas or, for that matter, the things that we do well.

Mrs Harvey —In my experience, people generally come to Australia to see how well we do it. Certainly, Southern Health in the Kingston Centre has an export program with Japan. They are always very interested in how we are conducting our aged care here, and they take some of those ideas back to their country and certainly try and implement them. I think that the social stuff is probably the critical factor, but we are on the right track. We have some really wonderful programs in the community, but they just are not as sustainable as we would perhaps like them to be.

Mr ANTHONY SMITH —It is interesting that people from other countries are coming here and seeing us as somewhat of a role model in certain areas.

Ms Houghton —We have had the same experience of overseas delegates coming to see how we are doing it and being impressed by a lot of the things that fit together with our aged care system. But I think there is always value in looking at any other models overseas.

Mr ANTHONY SMITH —Yes.

Ms Houghton —I think that is the way that we can improve on what we have been doing. I support what Gail was saying about a social approach. Perhaps it would take it away from the health focus that sometimes, I think, dictates things.

Ms HALL —I still have two questions to ask. One is that you mentioned the treatment of older people in hospitals. I would like you to expand a bit on that. In doing so, discuss how the process between hospital to referral to facilities or an appropriate community program works. Also, I would like you to talk just a little bit about the stereotyping of older people in hospitals and the general treatment, per se.

Mrs Harvey —I think that older people, like any group in the community, get unwell and need to go to hospital, whether that is through fractures or a medical episode of ill health. But, once that is over, hospital is certainly not the place for them to be, primarily because the care that they require is not geared for an acute sector. Hospitals are where people are sick and they stay in bed or they just sit by the bed—there is no extended therapy once that acute episode is over. People become a little bit more deconditioned and, therefore, their chances of perhaps returning to their prior place of residence are reduced and often permanent care becomes the outcome. Also, there are problems with the stereotyping of what they call `bed blockers'. It is a common linguistic thing in hospitals to say `that person is blocking a bed that someone else could have'. There is a lack of interim care, when residential care is the choice, to move them out of the acute sector to some place that is more conducive to a normal lifestyle while they wait.

Ms HALL —Is there a need for some sort of transition placement?

Mrs Harvey —Yes.

Ms HALL —Is there anything like that anywhere in Victoria?

Ms Houghton —I think that there is. The Innovative Pool Scheme is happening at the moment. It will be interesting to see how that works and how well people are chosen for that process. There is no point in treating it like a parking lot. People have to be able to access adequate ongoing therapies so that they do not, as Deborah was saying, get deconditioned—so that they are not needing a higher level of care than perhaps they should be.

Mrs Harvey —Once upon a time there was a thing called `convalescence care'. People would leave the acute sector and go to a bit of convalescence care and then go home. The convalescence care concept has well and truly disappeared, so there is nowhere for people to go just for that little bit of extra improvement time before discharge. I think that is what is lacking for older people—that convalescence type of care, helping them return to their pre-existing place of residence.

CHAIR —In Victoria, do you have any step-down facilities?

Mrs Harvey —There are interim care facilities, but they are primarily for permanent care. There is no step-down facility for someone who perhaps just needs a bit of a brush-up but not rehab. Rehab is just that little bit of extra intervention to help them get back home.

Mrs Thorn —The state government is currently funding three different models of interim care. One is the hospital based interim care model, which we have at the Austin and Repatriation Medical Centre. The second one is a residential care facility based model, where you purchase some unfunded beds and there is funding for hospital demand management projects. The third model is a community based one where if a family want to give it a go because they are not sure their mum really needs to go to residential care, but they are not sure of the demands, they are supported through that. Those models seem to be working quite well, but it is that transition. For some people there will be an improvement and they will be able to return home and manage okay for a bit longer with community resources. You might be advocating priority for them for a community aged care package or sometimes HACC services can sustain them adequately. But those three models are operating.

Ms HALL —This inquiry is looking to the future. What do you think should be in place? Can you put four or five points before us on what you think government should be doing to address the issue of ageing and the needs of people as they are getting older?

Mrs Thorn —I know I am going to be one of them! I would really like to be able to stay at home and I am prepared to pay for or contribute to the cost of my care to stay at home. To me, it is really important to be able to stay at home. We know that in 40 years time the incidence of dementia will be 3[half ] times what it is now but our population will have increased by 40 per cent. So if I am the carer and my husband has dementia I would really like the necessary carer support. One of the hardest things, and the things that can break down, is that carer burden, whether it is for the necessary medications, the in-home respite, the residential respite, all those services that will support me in caring for him—or him for me—in the future.

Ms HALL —What about equity for people who cannot afford to pay?

Mrs Harvey —Yes, I would like to see a higher amount of Commonwealth funding to the programs to make them more sustainable. There are going to be people in our community who can afford to pay, but there is also a high proportion who cannot afford to pay high costs to bring in services for their care recipients. That will continue to be the case, I am sure. So we need to be looking at what we provide and making it cost effective, but at the same time not be in the position we are in today where services are being reduced in order to make the budgets balance. The financial arrangements in place need to be working better so that a local government service can provide the appropriate home care or a CACPS provider can provide the required services, so that any program out there can meet the demand. That obviously involves a fairly big shift in policy in terms of how much of the gross domestic product comes to aged care. But if we are serious about what we need in the next 40 years, resourcing is a fairly big part of that.

Ms O'Donnell —I have one wish I would like to make—if this is the wish list?

Ms HALL —Yes, this is the wish list.

Ms O'Donnell —My wish is that we have more flexible options. Elderly people do not just sit in little squares, but that is the way we like to think and to fund—and it does not work. We need to have more flexible options so that people can have small bursts of rehab and then go back into the community and there is some continuum of care. We have to realise that acute care plays an important part in the life of an elderly person—they do need to have admissions—but it is not the end of the world when they go in. We have a sense now that once they get in there it is difficult to get them out and back into the community. We do need to see where we all fit and to try not to have these silos of funding. If we have flexibility we can actually be more efficient. We are not particularly efficient in some areas now. That would be my wish.

Ms Houghton —I would like to see more cooperation between levels of government, particularly state and federal. Regardless of political persuasion, it is a common problem that they have to grapple with together rather than having a bit of buck-passing between the two, which makes it very difficult for services like ours that are trying to be answerable to both. Finally, ACASs really need to be resourced adequately to be able to meet all these things that we are trying to grapple with.

Ms HALL —Excellent. Thank you.

CHAIR —Thank you all very much for appearing before the committee.