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Residential and community aged care in Australia

CHAIR —Welcome. Information on parliamentary privilege and protection of witnesses and evidence has been provided to you. The committee has copies of your submission. Do you have any comments to make on the capacity in which you appear?

Mr Yates —Yes. COTA Seniors Voice is the South Australian member of the COTA Over 50s group. As of 1 April, I will also be the Acting Chief Executive of COTA Over 50s for a period.

CHAIR —Thank you. I now invite you to make a short opening statement. At the conclusion of your remarks, I will invite members of the committee to put questions to you.

Mr Yates —Thank you for the opportunity to talk to our submission; it was brief, but we would be happy to enlarge both here and later, if need be, on any aspect of it. Just in opening and to provide a context, we would say that, while there is a great deal of public debate at present around the costs of funding high care, we would like to see that put into the context of thinking about a new framework for aged care. The need to articulate that is something that we argued to the previous government and to this government, when it was in opposition. There is growing recognition in the sector that this needs to happen. At our instigation, the National Aged Care Alliance—which, as you may be aware, brings together a wide variety of organisations in the sector and of which we are a sponsor member—is now working on a new vision of aged care and will produce a document probably at its May meeting.

The bare bones of the directions in which we think aged care ought to go are set out in our response to your term of reference (f). But, in summary, we really start in the health system itself, talking about a much greater focus on illness prevention and health promotion amongst older people. We do not think the value and importance of illness prevention and health promotion for older people is as accepted and understood as it is for the younger end. We then see transition into HACC, Home and Community Care, as a front-line support, providing fast, flexible, responsive and consumer-directed supports to people to get on with their lives. We do not support the habit that has developed over the years of HACC being packaged up into quite substantial packages of care because there are no other alternatives. HACC is supposed to be there at the front line of support for older people in the community.

Moving to what we now call care packages, we believe they ought not to be bundled in the way they currently are but essentially should be an amount of funding based on an assessment of that person by an assessment team. Although I take the point of the previous witnesses that we could build some strengths into the assessment process—I might say a bit more about that later—we believe that it should be styled not to say that you are a CAPP or unique but that you have a certain set of needs, with a set of money coming around that. In passing, I would say that we particularly need that access to be through standardised and equitably accessible Aged Care Assessment Teams around the country—and that is very variable at the moment.

CHAIR —I am sorry; I just did not hear that word.

Mr Yates —‘Variable’—how long it takes you to get into an ACAT and the quality of the assessment, we would argue. Probably the most controversial part of our recommendation is that essentially we are saying that there should not be any quotas with the provision of packages of care. The ACAT is the gateway. If you meet a rigorous standard of being assessed for need, you ought to be funded. The parallel there is with the health system: we do not have quotas for how many people can see a GP or get into an emergency department. Providers should be approved, but the packages should not be given to the providers and should not be assigned by region. Basically, this kind of system is not recommended, but it is advocated gently in the Productivity Commission’s discussion paper on aged care.

With residential care, the accommodation component needs to be separate from the care. We will always have a need for residential care, but we would like to see much more emphasis on community care. We do not think you can really assess the need for residential care until you have fully met the community care needs. We are supportive of the greater accommodation choice for people, which we think that would bring. In terms of user contributions to both care and accommodation, we set out some principles of transparency, equity and comparability—that is, can I actually tell, as a potential resident or the family, what the different costs for me would be across different providers? In that context, we support much more flexible payment options—periodic payments, discounted lump sums, prepayments or loans.

We believe that the whole system needs to move to a more consumer directed care model, with much greater involvement of consumers and their carers. All of that is based around a paradigm of our needing to see older people as not having a ‘best by’ date. We need to see them as being able to make contributions and being supported, with their strengths built upon, encouraged and challenged. That is how we ought to recast the system that we have at the moment.

CHAIR —Thank you for those comments.

Senator HUMPHRIES —Thanks for your presentation; I am sorry that I missed the beginning of it. Did you make a comment in your opening presentation—I do not think you made one in your submission—about whether COTA views aged care accommodation bonds as being an appropriate device to deal with funding shortfalls in the sector?

Mr Yates —In the early part of my opening remarks, I said that we really want the funding discussion recast into a redesign of the system. If the kinds of principles that I was outlining about costs for a consumer are in place, we think the consumer also ought to have choice about paying a periodic payment, paying a discounted up-front prepayment, paying a loan—which, in this environment, is called a bond but in many other environments would be called a loan—or a mix of those things. The different consumers and different family situations will lend themselves to different contexts.

Frankly, discussion about having a high care bond or not, to my mind, has us caught in the wrong discussion. The discussion ought to be about what kind of care spectrum we have and how we resource it. Then people ought to be able to pay through whatever mechanism suits them; but it ought to be transparent and comparable so that people can actually make decisions.

As we say in our submission, we think the distinction between low and high care is increasingly not relevant to the care spectrum—and I am happy to talk about the ACFI—when the ACFI essentially says, ‘Look, let’s assess you against a whole lot of criteria and come up with need.’ Essentially, the division of that into high and low care is a bureaucratic device that has been designed because the act says that you have to have one.

The other thing that is happening is that, based on those assessments, the way that people approach their client mix is distorted by that funding provision. You have one lot of clients with whom you can have one type of funding relationship, but then you can have another—and, of course, if they do move from one to the other, the rules change as well. To answer your question in blunt terms, in that context, we do not have an issue with bonds for high care, provided that you have choice, transparency, comparability and equity—that people do not get excluded from any care if they cannot afford it.

Senator HUMPHRIES —I suppose that is a critical question, isn’t it—how you make sure that people on low incomes are still able to access affordable places?

Mr Yates —Yes. In the current system there are provisions in place for government to do that. We argued before the internal CAP inquiry—not before the main CAP inquiry, as we did not appear before that one—that that discussion needed to be broadened into funding adequacy and mechanisms, because CAP was only ever a transitional provision anyway.

Senator HUMPHRIES —In that sort of deregulated multiple-choice environment, you say that you have to cater for those people on lowest incomes in order to make sure they have access.

Mr Yates —Yes.

Senator HUMPHRIES —What do you do about the notion of profit as a part of this sector? Does that invite more of the for-profit providers to enter the sector; and, if so, is that a problem? Does that distort the way in which we provide aged care or its quality?

Mr Yates —There are two different answers to that. One is that, in terms of opening up provision and increasing choice for people and, therefore, in that sense, creating a consumer directed market, we think that providers still should be approved. So, while you do not give them all of the regulation or the packages as now—they go with the consumer—you still have to be an approved provider. In addition, we still believe that you need standard setting, monitoring and follow-up. All of that applies, and there are other parallels of care for other sectors of the community for all of that.

The second thing to say is that, whether you are a non-profit provider or a for-profit provider, you have to run your business on a profitable basis. Some of the most profitable providers in the sector are not-for-profits; that just means that their money does not go off to shareholders. In terms of scale, I think we will see a number of the smaller for-profits not surviving in the future aged care market; situations of scale and capacity to handle this kind of complexity will mean that they will not—and there has never been a problem with some people being in the industry for profit. Everyone has to have a margin, I guess.

There are issues, I am sure, that my colleagues who follow me will talk about, such as the tax advantages of not-for-profits compared with those of for-profits. We see high-quality for-profits and high-quality not-for-profits and some on both sides of the fence that are not quite as high quality.

Senator HUMPHRIES —On page 3 of your submission, you make a comment about differential access to care and appropriate care. You state:

... the greater inequity between consumers is that of differential access to care and appropriate care. This is a function of a number of factors, including ... the current distribution of beds and places, the structure of the age care industry ...

Can you explain what you mean by that paragraph?

Mr Yates —We mean that in different parts of the country, as is reported to us and as we understand from the figures, it is harder or easier to get access to care, and we do not think that should be the case. We also think the way that the packages are structured at the moment creates complexities. You can have quite absurd things resulting from the packages being allocated by region and provider. Somebody in a region next door to another can need a package of a certain type—say a dementia package—but no-one has that in that region; however, there are some spare ones in the next region. So you get people saying, ‘No, we won’t assess you for the higher level of need, because you’re on a CAPP now and that’s all we’ve got to give you.’ That is not a rational or compassionate system. That goes to our argument that you need to free up the funding around the person and their needs and then let the providers provide, because you have a ticket.

Senator HUMPHRIES —So, if a person qualified for that kind of care in terms of their level of need and their financial circumstances, they should be able to attract that funding wherever in the country it happens to be.

Mr Yates —Absolutely, and from a provider of their choice who has been approved by government. We would also emphasise that, in terms of inequity and according to the official data, both anecdotally and my understanding of it, access to assessment around the country varies in terms of time and quality. I am sure that departmental staff could talk to you about pursuing that issue between the Commonwealth and the states. For the sake of proposing a benchmark, we have said in here that, if something has arisen and you have a need, you ought to be able to get an ACAT assessment within five working days. Getting the support early that that assessment provides you with is quite critical, because people can escalate in terms of their needs if they are not addressed quickly. In some places you can get ACAT assessments very quickly and in other places waiting lists of weeks and months are not uncommon. I do not think the government of the Australian Commonwealth should accept that. We, as consumer advocates, find that unacceptable.

Senator CAROL BROWN —You mentioned earlier—I am sorry, but I did not quite catch what you said—an alliance.

Mr Yates —The National Aged Care Alliance.

Senator CAROL BROWN —Can you tell me what member organisations are part of the alliance?

Mr Yates —We can send a list of those to you. Probably most of the people appearing before you today are members of it. It is a mixture of the key consumer groups: ourselves, Alzheimer’s, carers et cetera; all the consumer peaks, one of whom is about to succeed me, and ACSA; most of the major aged care providers, particularly church and charitable ones, whose national representatives attend; union bodies such as the ANF, HSU and so on; and the professional organisations—I do not know whether you include the AMA as a union or professional organisation—such as physiotherapists and so on.

Senator CAROL BROWN —It depends on the issue, I think.

Mr Yates —All of those organisations sit around the National Aged Care Alliance table and we put a lot of energy into discussing issues such as these and trying to come to common positions; we do not always manage to do so, but we all benefit from that sharing. NACA puts submissions on aged care issues regularly. Indeed, our next meeting will be in Canberra towards the end of May, and our first day will be in parliament dealing with aged care reform issues.

Senator CAROL BROWN —What sort of consultation did COTA have with its members on the high care bonds issue, which you have put before us today?

Mr Yates —Widespread. All of our state and territory COTAs have policy councils. It is probably fair to say that the extent of consultation out into the community varies from state to state, just as the memberships vary. In my case, in South Australia, we have individual membership of about 20,000 people and we have membership of 300-something clubs and senior organisations, so we consult widely. This has been a matter of discussion for quite some years. As I have said, it is not a debate that we like phrased in terms of whether you should have bonds in high care, when essentially we are saying that you should not have high or low care. You should have a classification instrument for care, and paying for accommodation should be a separate issue. You should work out what your user contributions are and then users and their families should be able to pay them flexibly in a way that suits them—and what will suit one may not suit another.

Our other caveat, I would emphasise again, is that we want it to be transparent. By that, I mean that we still come across situations where low care providers essentially trawl the assets of potential residents to see how big a bond they can knock up. It needs to be transparent and it needs to be accountable and comparable. An example would be the attempts made at state level to introduce much greater transparency into retirement village loan license agreements so that people essentially going in there can compare things on a similar basis.

Senator CAROL BROWN —So, basically, your consultation process was about funding being allocated to beds.

Mr Yates —Actually, our consultation outcome was that funding ought to be allocated to the people.

Senator CAROL BROWN —But it was not particularly about high care bonds.

Mr Yates —No; but that issue is there and it has been a lively debate within the organisation. The position in here is the consensus position of the organisation through its national policy council.

Senator CAROL BROWN —So COTA’s position on funding being allocated to people is the same position you would take with respect to CAP packages and HACC.

Mr Yates —HACC, we think, is more complex. With HACC, in some cases, you are providing what is essentially community-development infrastructure and services, but we would like to see it being much more client focused than it is at the moment. We think the principal distortion for HACC is that it gets used to create packages because the packages or care system in the community is insufficient. The really big thing that our consultation has told us for over a decade is that consumers want more and more robust community care and community care with much more flexibility in it. They want it to be available at the time they need it and so that it meets their needs. There are too many people in, firstly, the healthcare system and, secondly, residential care because they cannot get access to community care.

Senator CAROL BROWN —You have made a comment in your submission that perhaps you could explain or elaborate on a bit further. You say:

This must include clear protocols that ensure that HACC is focused at the ‘front end’ of both individual and community support and not converted into high level packages of care.

What do you mean by that?

Mr Yates —When HACC started its data collection process so that it could track who was being provided with what kinds of services, one of the things that was found was individuals with levels of service that, in terms of value, exceeded those of each package. Consumers that we talk to define HACC as assistance, support and help to get on with living rather than care, and the care becomes more of the assessed process and is a series of packages. So we have found that people are receiving HACC services cumulatively that add up to more than packages. In our view, that is not what system was designed for. Also, at the moment, at a really detailed level, you have situations where people will not move off HACC services and on to packages, because of the different consumer funding arrangements; but I am sure that you have had evidence about that already. That is part of a by-product. Obviously, we are aware that the issue of the future of HACC is part of the COAG process at the moment and, in that context, we argue a similar line for continuity of services.

Senator BOYCE —We have had evidence from service providers about what I suppose could be described as a fairly toxic relationship with the accreditors, where staff feel intimidated and so forth. Obviously, this has to be balanced against the fact that we want a safe environment for people who are in residential aged care. Does COTA have a view on this or an involvement in the area?

Mr Yates —Certainly, because we maintain a very active liaison and consultation with the providers—

Senator BOYCE —It is the consumers that this is all about, one hopes.

Mr Yates —It is. But a provider has a whole lot of imperatives from the provider end that are quite legitimate interests, so we encourage that we ought to be in dialogue about those things. The National Aged Care Alliance, which I have mentioned, creates that opportunity, so that issue is often discussed at the alliance.

We are very keen to see forceful, vigorous pursuit and, indeed, review of the standards. We know that things happen in residential care and in community care that are not good. My South Australian organisation auspices the Aged Rights Advocacy Service in South Australia and we very regularly come across cases that are really appalling. Often the industry does not want to deal with or know about such cases. I do not mean that it wants such cases to happen; it is an issue for them to deal with.

One of the approaches that we have taken is to work with the industry on how you deal with culture and with changing the attitude of staff. This is being done not from a punitive perspective but from the perspective of building a positive and understanding culture. Frequently this operates out of a conception of older people that is very ageist and which essentially sees them not as people, and we are working with the industry to shift that. Quite a lot of response to that is coming from the industry—we hear many of the things that you will have heard—and we think that is not necessarily effective. We would be willing to be part of a dialogue with the agency about how they do those things more effectively, because I do not think that toxic relationship helps at all. I have to say also that essentially, in a lot of policy discussions in which we are engaged, that is what we observe. In addition, we observe a kind of dance between the department, as funder, and the industry. Then every now and again we knock and say, ‘Excuse us; we’re over here. We’re supposed to be what you’re here for.’

Senator BOYCE —‘We are the reason that you are all here’?

Mr Yates —But, as I said in my opening remarks, through the alliance, at least the peak sections of the industry are engaged in a very constructive discussion now about where this industry ought to be in 10 years time.

Senator BOYCE —I guess my next question has to be: does the alliance talk to the agency as an organisation?

Mr Yates —It attempts to talk to the agency and currently—this is not the agency; it is more the department—we are preparing a new paper on the complaints system to try to deal with some of these issues. We will have that available, hopefully, in May. Sometimes it takes a long time for the alliance to sign off on papers because we have a consensus process.

CHAIR —Thank you very much for appearing before us today and for your submission.

Mr Yates —Thank you for allowing our organisation to be here. We would be happy, if any questions arise later, to give you additional information.

CHAIR —Likewise, if you have any additional comments to make following on from today, we will be happy to receive them.

[11.46 am]