Aged Care Policy Blueprint for 2020 Aged Care...Aged Care Policy Blueprint for 2020 ‐ 3 ‐...

Aged Care Policy Blueprint for 2020

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Contents

Foreword.....................................................................................................................3

Executive Summary .....................................................................................................5

Catholic Health Australia..............................................................................................8

Catholic Health Australia Aged Care Vision ..................................................................9

Catholic Aged Care Planning Principles.........................................................................9

Catholic Health Australia 2020 Key Goals – Aged Care..................................................9

The Catholic Health & Aged Care Sectors ...................................................................10

Australia’s Aged Care Challenges ...............................................................................12

Australia’s Aged Care Policy Environment ..................................................................15

Demographics............................................................................................................18

International Experience of Aged Care .......................................................................20 Aged care in OECD countries.............................................................................................. 20 Recent international innovations in public programs for long term care ............................ 21 Consumer Directed Care (CDC) .......................................................................................... 22 Summary........................................................................................................................... 22

Consumer Directed Care Programs.............................................................................23

Population Based Funding..........................................................................................23

Next Steps .................................................................................................................25

CHA 2020 Vision Plan for Aged Care...........................................................................25

Implementation 2008 ‐ 2011 ......................................................................................27

REFERENCES...............................................................................................................31 Copyright Catholic Health Australia ABN 30 351 500 103 Published by Catholic Health Australia, 2008


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Foreword: Martin Laverty, CEO Few working age Australians consider the needs of their retirement. Fewer consider their personal care needs. If any thought is given, most plan to live in our own homes. This in part explains the justified policy focus on in home care. Policy attention on in home care has come at a cost to policy for residential aged care. The last major reform of residential aged care occurred in 1997. Those reforms produced a system that eleven years on is now stalling. One in nine residential aged care beds in Australia is provided as a service of the Catholic Church. The Church provides these aged care services as part of its commitment to caring for any Australian who because of their age or frailty finds themselves in need, regardless of their financial and religious backgrounds. Current residential aged care policy is restraining the ability of Church and other aged care services to meet consumer need. Quality standards, service funding, access to capital, and consumer charges are tightly controlled by Commonwealth law. Regulation limits aged care supply. Regulation restrains consumer fees. These factors together prohibit the use of market price signals, resulting in limited choices for where and when consumers can access services. The result is an aged care market not structured to meeting the best interests of the needs of its vulnerable consumers. With one in every nine residential aged care beds provided by members of Catholic Health Australia (CHA), we find ourselves as the largest grouping of not for profit aged care services. Providing one in nine beds, our members speak with direct experience of the operation of current policy settings. Having identified the need to change these policy settings, we now seek a partnership with the Commonwealth to do just that. The blueprint that follows is a product of wide consultation with the operators of Catholic aged care services. A two day strategy meeting was held in Sydney on July where CEOs of Catholic services shared their experiences and outlined the failures of the current policy framework. CHA staff then refined these contributions into the blueprint that follows. In the coming months, CHA will be reaching out to the Commonwealth and other aged care policy thinkers to build the case for policy change. CHA is not alone in its views, with most other not for profit peak bodies sharing similar aspirations. The urgency of the need for change should not be understated. With 40% of services facing financial challenges, with some deciding not to expand their services, and with aged care staff being increasingly hard to find, action is required. Action is required now ‐ before the ‘Baby Boom’ bulge hits. Martin Laverty Chief Executive Officer November 2008


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Executive Summary The last major reform of residential aged care policy occurred in 1997. The benefit of those reforms has now been exhausted. The first major reforms of aged care policy occurred under the Hawke Keating Government. CHA considers that it is time for the next major reforms to be implemented and that it would be appropriate for these to occur under a Rudd Government.

This policy blueprint is the outcome of a consultation with members of Catholic Health Australia (CHA). One in nine residential aged care beds in Australia is provided through services operated by different bodies of the Catholic Church. CHA, as the peak body for these residential and home care services, speaks on behalf of the largest grouping of aged care services in the Australia.

CHA adopted in July of 2008 a new vision for aged care which it seeks to see achieved by 2020. This vision is of equity of access to aged care services for all Australians, with a preference for those living in socioeconomic disadvantage.

CHA’s key goals for aged care are that:

1. Older Australians receive the care they need in the accommodation of their choice, whether in their own home, in the community or in a residential facility.

2. Demographic based funding will be oriented to ensure the delivery of excellence in person centred, compassionate care.

3. The funding framework will ensure that the care of older Australians is delivered by an appropriately skilled and qualified workforce.

In seeking to achieve this vision CHA has produced this blueprint for policy change, which it offers as a plan for how improvements in aged care services can be achieved.

Residential aged care is currently regulated and funded by the Commonwealth. Commonwealth regulation limits the allocation of residential aged care beds and the user fees that can be charged for their provision. Commonwealth operational funding is insufficient in that it does not relate to the actual cost of service provision. Subsequently, in October 2008 the failure of this regulatory and funding mix was highlighted again with overall average earnings for aged care providers having dropped away by 10% in just one year and the estimated average return on investment for new, single room facilities as now 1.1% and falling1.

The challenges being faced in Australia are no different to those being faced internationally. The United Kingdom and Sweden, who have principally funded aged care services from the tax system, are encountering problems relating to the scarcity of revenue. These countries are moving away from solely tax payer funded arrangements. In Australia, aged care funding is not solely tax payer funded, yet the ability to fund it from user charges in unreasonably limited.

To the extent that the Commonwealth does fund aged care services, its funding is insufficient. From March 2008, a new funding instrument (the Aged Care Funding Instrument) appears to be compounding the problem as high care admissions (that are not able to charge bonds) replace low care admission (where a bond can be charged) and many older people with social and psychological needs (who do not attract sufficient funding under the new instrument) may go without residential aged care due to their lack of financial means or lack of available appropriate residential aged accommodation.

1 Grant Thornton Aged Care Survey 2008, summary findings October 2008


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In looking to bring about reform, this blueprint makes a number of key recommendations. CHA argues reform should not be piecemeal. Rather it should include revision of how consumers plan for their entry into aged care, how they are assessed for entry, how aged care services are licensed for operation, how services are funded, and how staff are trained and rewarded for their role as care givers. The importance of this final focus on staff identification, training, and retention can not be under estimated. If action is not taken to build the care giver workforce of the future, there will be inadequate numbers of care givers to look after those Baby Boomers who are soon to enter care.

With the Baby Boom bulge expected to peak around 2030, Australia needs to be ready for an increase in demand for residential aged care. At present, some aged care operators are refusing to develop new residential services because the risk of doing so outweighs the incentive. Action must be taken to reverse this trend.

To be ready for the residential aged care needs of the Baby Boom bulge, CHA in this blueprint has provided an assessment of current policy settings, a summary of international comparison, and a policy plan for achievement of aged care reform. Most importantly, CHA’s plan for reform does not expect Government to fund all service provision – it expects Government to contribute financially in a manner that reflects actual cost of service provision, but it also expects Government to free up current constraints so that consumers can better contribute to their own care where they are financially able to do so.

Within the Blueprint, some of the key recommendations for reform include:

• A new consolidated single funding program linked to actual cost of service provision. Funding of aged care is currently provided by a multitude of Commonwealth and Commonwealth/ State/Territory funded programs. A single, simplified and consistently applied national aged care program would better enable older Australians to receive the right care, in the right place, at the right time.

• Aged Care Assessment Team to be fully funded and managed by the Australian Government.

This service would ensure consistency of eligibility is applied, and that there is no conflict of interest when undertaking assessments.

• Consumer Directed Care. Consumer Directed Care provides choice and control. Consumers are

able to choose which services they receive and who will deliver these services and when. CHA believe that aged care service consumers in Australia would benefit through increasing consumer choice by way of vouchers or managed purchasing of aged care as a possible alternative to direct funding of services.

• Localised population based funding. A population approach would facilitate equitable access to

aged care services. By establishing indicators of need across regions, Government would be able to ensure greater flexibility and responsiveness in service delivery.

• Removal of limitations on consumer fees. Commonwealth regulation currently prohibits an aged

care service from determining the cost of its service that is purchased by the consumer. Re‐regulation would allow the user fee to reflect the cost of the service, and give consumers choice in the type of service they seek. Safety nets, such as those already provided by Catholic aged care services in the form of subsidised concessional beds would be required for those unable to meet service costs themselves.

• Abolition of the distinction between low and high care. With changes in the needs of those

entering care, the technical distinction between low and high care is becoming increasingly irrelevant. The merger of low and high care would also require the review of the regulatory


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requirements for each category, allowing bonds to be levied for all residential aged care where the consumer and provider agree to do so.

• An innovation fund. Creation of an innovation fund that promotes a leading edge approach to

person centered aged care, and ensures the dissemination of this research.

• A National Health Workforce Commission that consolidates all current initiatives aimed at the health workforce planning and development, with a specific mandate to provide skilled workers for community and residential aged care services.

• Increasing Superannuation to 15%. The ability of future retirees to fund their aged care service

needs is likely to be directed by the availability of funds at their disposal. Superannuation should be increased to its originally proposed 15%, with consideration to be given to the quarantining of a portion of superannuation payouts to be available specifically for purchase of aged care services.

• Creating insurance products to contribute to aged care. More than 40% of Australian’s are used

to the concept of self insuring for their health care. Australia’s health system depends on a strong pool of consumers with private health insurance. Private health funds and other insurers should be given incentives to develop products to fund future aged care.

In preparing this blueprint for policy reform, CHA is seeking to contribute to Government planning for the future of aged care. Few if any of the proposals for reform described here are new. Rather their failure to be acted on by previous Government’s speaks to the urgency for action. CHA looks forward to working with Government to achieve the future vision of equity of access to aged care services, for all Australians, with a preference for those living in socioeconomic disadvantage.


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Catholic Health Australia Catholic Health Australia is a Leadership Group established by the leaders and owners of Catholic health and aged care providers in Australia. Vision Catholic Health Australia seeks an active, effective and growing ministry which is inspired by and reflects the healing mission of Jesus. Mission Catholic Health Australia’s Stewardship Board has the responsibility to develop and enhance effective relationships within the sector to grow and enrich the ministry. Taking Responsibility Catholic Health Australia’s Stewardship Board will exercise its responsibility through:

o Sector leadership o Planning assistance o Policy formulation o Leadership development and formation o Advocacy and representation

Targets

o Growth in Ministry o Advancing a Fair and Just Society o Development of Sector Orientated Activities


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Catholic Health Australia Aged Care Vision Equity of access to aged care services, for all Australians, with a preference for the socio economically disadvantaged.

Catholic Health Australia’s vision for the future is one in which there is access to quality living options and

care services that are linked and integrated, for all – because we value older people and they value themselves.

Catholic Aged Care Planning Principles 1. Policy integration that avoids a siloed approach to program planning and implementation.

2. Integrated services are person centred with consumers and or their representatives in control of their care planning and delivery.

3. Access to coordinated care is equitable.

4. Evidence based processes are at the centre of policy development

5. Sustainability of policies.

6. The service delivery framework is oriented towards encouraging quality improvement in response to consumer demand.

These planning principles provide a framework for policy development across the continuum.

Catholic Health Australia 2020 Key Goals – Aged Care 1. Older Australians receive the care they need in the accommodation of their choice, whether in

their own home, in the community or residential facility.




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The Catholic Health & Aged Care Sectors Catholic Health Australia (CHA) is the largest non‐government provider grouping of health, community and aged care services in Australia, nationally representing Catholic health care sponsors, systems, facilities, and related organisations and services. CHA was established in response to a sector wide process that aims to promote and strengthen the organised expression of the Catholic health ministry. The healing ministry of Christ is an integral part of the Church's mission. In Australia Catholic health care has a rich tradition of more than 160 years of commitment and service provision to the Australian community. The sector comprises providers of the highest quality care in the network of services ranging from acute care to community‐based services. These services have been developed throughout the course of Australia's development in response to community needs. The services return the benefits derived from their businesses to their services and to the community; they do not operate for profit; they are church and charitable organisations. The sector plays a significant role in rural and regional Australia, demonstrating its commitment to the delivery of services where they are needed irrespective of whether any or minimal return on investment is derived. The Catholic health ministry is broad, encompassing many aspects of human services. Services cover aged care, disability services, family services, paediatric, children and youth services, mental health services, palliative care, alcohol and drug services, veterans' health, primary care, acute care, non acute care, step down transitional care, rehabilitation, diagnostics, preventative public health, medical and bioethics research institutes. Services are provided in a number of settings, for example, residential, community care, in the home, the workplace, hospitals, medical clinics, hospices, correctional facilities, as well as for people who are homeless. In addition, services are provided in rural, provincial and metropolitan settings, in private facilities as well as on behalf of the public sector. The sector plays a significant role in Australia's overall health care industry representing around 13 percent of the market and employing around 35,000 people. The Sector Snapshot

o 19,000 residential aged care beds o 6,253 retirement and independent living units and serviced apartments o 8,000 Community Aged Care packages (CACP) o 6,000 Home and Community Care programs (HACC) and Extended Aged Care at Home packages

(EACH) o rural and regional aged care facilities and services o 9,500 beds in 75 health care facilities ‐ publicly (21) and privately (54) funded hospitals and o 7 teaching hospitals o 8 dedicated hospices and palliative care services o expanding day centres and respite centres o approximately 35,000 people working in the sector

Why Catholic Aged Care? In Australia, the Catholic Church has played a pivotal role in demonstrating a model of health, aged and


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community care that often uses private resources to meet public health goals. Partnerships between the public and private sector deliver high quality outcomes, that are shaped by the mission and values of the organisation. CHA facilities serve the sick, suffering and dying and respond to the needs of people and communities by maintaining affordable access. Catholic aged care services are both communities of service and communities of work. Their reason for being, and the basic orientation of all their personnel, are respect for the dignity of every person and concern for the total well being for their residents. They affirm centrality of the resident and recognise the importance of family, friends and the wider community in the caring endeavour. Underlying the care given is a comprehensive understanding that includes attention to the need for a balance of the biological, psychological, social and spiritual forces that interact within the person, society and our environment. The Catholic Church is the oldest and largest provider of health and aged care in the world. Catholic hospitals and aged care have commonly evolved from ‘family concerns’ set up by congregations of religious sisters and their generous benefactors. Their Ministry has been built around the ‘charism’ of the various religious orders responsible for the early development of services across the world and also here in Australia. The distinguishing feature of not‐for‐profit institutions is that legally and morally they owe their duty to the community they serve. Unlike investor owned organisations they are not designed for the purpose of providing a return on capital to shareholders. Catholic aged care services have focused on the following key elements of care: 1. Holistic care‐ understanding a person’s physical, emotional, social and spiritual needs. 2. Respect for life‐ services respect the inherent dignity of persons, recognising that all are created in the image and likeness of God. 3. Social accountability/community responsiveness‐ programs are concerned about the needs of communities and individual people within communities. 4. Stewardship‐ Catholic sponsored organisations are good stewards of limited resources. 5. Catholic identity‐ Catholic sponsored organisations are Ministries of the Church. Catholic aged care services can and should be agents of change, advocating for public policies that challenge and transform our communities in new ways of dealing with social problems. Social responsibility places special demands on Catholic aged care organisations. Whilst they cannot take on every societal injustice, they can discover opportunities for effective action. By linking with others, Catholic aged care organisations can make a significant contribution to changing the social and economic forces that oppress people.


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Australia’s Aged Care Challenges The Productivity Commission research paper, titled Trends in Aged Care Services: Some Implications (September 2008) analyses major trends in both demand and supply within the Aged Care Sector over the next 40 years. The study draws out implications for the future structure and mix of aged care services, the aged care workforce and for the capacity for greater productivity in the sector. Emerging opportunities for improving productivity include greater use of: information technology (although cost is often prohibitive); assistive technologies that allow individuals to perform tasks that they would otherwise be unable to do, or to increase the ease and safety with which tasks may be performed; changed work practices through the use of innovative workplace agreements; restructuring of activities; and most importantly regulatory reform. Detailed below are several domains that provide government and aged care providers with challenges for operating into the future. Diversity Aged Care policy has tended to assume that older people are an homogenous population group – but older people are as diverse as any other part of the population. Policies and programs that use age as a criterion for exclusion may not deliver the most appropriate health care response. The differences within this population group are important to understand if the system is to respond effectively to the diverse health needs of older people. Linear thinking CHA notes concerns expressed in relation to the impending demographic changes and the burden that older people will place on the community, particularly the anticipated baby boomer bulge. This concern can lead to the perception that older Australians are simply a cost burden. Government should actively support and promote the value of older people as an integral part of the community fabric, and foster a greater understanding that ageing, or growing older, does not necessarily equate to a linear decline. Greater flexibility and improved linkages are needed to avoid this narrow, economic rational approach to policy development. Older people have the potential to move in and out of services and mechanisms must be developed to facilitate this process – continuously. Interestingly for Government older people as a proportion of all voters will continue to increase over the next half century. Our service providers and communities tell us there is unmet need particularly in relation to Home and Community Care Services (HACC) – with growing waiting times to gain access to care. It would be useful to quantify this unmet need, particularly to inform the development of new funding models. The programmic nature of residential aged care, rehabilitation and sub acute services does not allow for ease of movement across programs. The future should see consumers being able to move in and out of residential aged care – back into their homes or into rehabilitation services. Future funding approaches should support this. Lack of consultation Policy that is uninformed by the population it affects will be inflexible and will not meet the needs of the population it is trying to serve. Hence CHA advocates for a policy process, or audit, whereby involvement of older people in planning, developing, evaluating and using integrated services occurs, in order to ensure that older people and their carers are central to the planning of these services. Policy processes Aged care policy in Australia has grown out of two distinct policy frameworks – the nursing home sector from a health policy framework centred around the hospital model, and the welfare policy framework


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where the need was essentially housing with limited support. The two systems have traditionally been independent of each other – it is only since 1992 that residential providers have become providers of community care. Staffing of aged care has emerged from the health sector and models of dependency. This is in contrast to, for example, the disability sector where service has been influenced by self determination models. Further analysis and unbundling of what lies behind staffing rationales particularly for residential aged care is required, in order to adequately and accurately plan for the future.

There has been a policy environment where there was little rational exploration of new policy directions and a great deal of personal intervention by politicians. CHA is hopeful that sound policy principles, as outlined by the Prime Minister in April 2008 to his SES staff2, will be adhered to in any policy development process under the Rudd Labour Government.

Seven elements of the Government’s vision for the future Australian public policy

1. Reinvigorating the Westminster tradition of an independent public service with merit‐based selection processes and continuity of employment when governments change;

2. Building a professionalised public service committed to excellence; 3. Developing evidence‐based policy making processes as part of a robust culture of policy

contestability; 4. Enhancing the strategic policy capability of the public service; 5. Strengthening the integrity and accountability of government; 6. Broadening participation in government through inclusive policy processes, and 7. A contemporary view of government service delivery that emphasises both efficiency and

effectiveness in outcomes.

In response to the Prime Minister’s suggestion contained in the 6th element above, that a more inclusive policy process occur, CHA has developed this policy blueprint for consideration.

Affordability There are serious short term operational and long term capital problems facing the residential aged care sector – these have been well documented. There are strict government certification standards ‐that are welcome – but the requirements leave the high care component of the sector heavily dependent upon cross subsidies from low care funding, or having to undertake redevelopments incorporating debt that is difficult to service. Overall there is a lack of access to capital funding which, into 2020, will be clearly unsustainable. Increasingly high care stock will not be built unless other means of accessing capital funds are made available, or certification standards are relaxed. Added into this mix is the increasing cost of wages and higher interest rates. It is estimated that currently over 40% of high care providers operate at a loss (Sammut. J., 2008). Lack of affordable, appropriate and available housing is also part of the ‘problem’. A fundamental reform that could be undertaken now is to ensure new housing stock complies with regulations that assist people to remain in their own accommodation for longer. Finally, there must be a recognition that into the future different consumers will have different abilities to pay for aged care services. Regulation The Aged Care industry in Australia is heavily regulated and according to Professor Warren Hogan this regulation allows providers to avoid competition, which would have the potential to create greater

2 Prime Minister Kevin Rudd Address to Heads of Agencies and Members of Senior Executive Service, Great Hall, Parliament House, Canberra, 30 April, 2008 http://www.pm.gov.au/media/Speech/2008/speech_0226.cfm, accessed 5/10/08


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efficiencies and improved quality of service (Hogan 2007 p6‐7). Whilst national competition policies are in place, with the ACCC being established in order to promote competition and fair trade in the market place in order to benefit consumers, businesses and community ‐ the aged care sectors ability to improve both efficiency and cost effectiveness is limited. It is argued that the degree of regulation that is in place exists in order to secure the provision of quality services, equity of access and gate keeping in terms of government expenditure – all laudable goals. CHA argue that these goals could still be achieved with a loosening of regulation – but not a complete deregulation. CHA call for existing planning and allocation systems to be abolished and for ACATs to become fully owned and controlled by the Australian Government. ACATs could then assess eligibility for a subsidy. This eligibility and subsidy could then be transportable and follow the consumer. This approach would assist in the implementation of consumer directed care models for the Australian Government subsidised Community Care Packages. Building certification requirements should be built into the existing Building Code of Australia, as a more efficient cost effective approach rather than as an additional certification requirement. Certification has imposed higher building and operational costs and decreased efficiency with no compensation offered via funding or indexation to cover these costs. In addition, regulations surrounding accommodation bonds have had the effect of reducing available capital investment within the sector. There is in any case a failure of current policy on bonds. Bonds can only be levied in low care. Yet ageing in place means there are effectively bonds in high care. This has increased high care bonds ‘by stealth’. CHA argues as the distinction between low and high care is blurring, the distinction should be removed and all residential aged care should be able to levy a bond. In order to grow capital investment, providers should be allowed to publish bed rental amounts and provide consumers with the choice of either a daily charge or a refundable lump sum. The current disparity between who is charged an accommodation bond and who is not creates perverse incentives. A bed rental scheme addresses this issue with the government providing funding for an acceptable minimum standard, hence ensuring the socio‐economically are not disadvantaged. It also offers greater flexibility and choice to the consumer.


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Australia’s Aged Care Policy Environment Individual ageing reflects a range of issues – health, income, social issues and public expectations. The major influences on aged care policy include the prevailing economic environment, public perceptions about ageing and attitudes toward older people and the dominant political party philosophy and beliefs in relation to aged care – which are informed by the first two influences.

In the past the aged person has provided particular policy challenges because of their potential vulnerability due to poor health, low income and limited informal support. What we see in the future is a population cohort that potentially will experience better health than their predecessors, have a higher disposable income but still experience limited informal support.

These issues provide complex challenges in the design and implementation of policy in order to deliver services that meet needs effectively. The longer‐term policy directions in aged care need to consider these changes, especially the raised expectations of the large baby boomer cohort.

Pleasingly aged care is slowly attracting a higher profile in health policy debates as a growing share of national expenditure is directed to this area. The effects of population ageing have not always been totally incorporated in the forecasts carried out for the purposes of public policy‐making, as the implicit assumptions in terms of life expectancy embedded in them are usually quite conservative. Clearly as populations age there will be a growing demand for aged care services within Australia, particularly when the baby boomer generation reaches ‘old old age’ after 2030. This will pose a continuing challenge for Government in seeking to balance provision of quality care with sustainable cost to both the public and private sectors. That is, balancing quality care with equitable funding. In Australia, aged care services cut across policy areas such as health, housing, environment and transport, that bring together a range of services for people who are elderly and who are dependent on assistance with activities of daily living over an extended period of time. Australia has tried to avoid fragmentation of service delivery and has invested in a number of high profile reports that look to the future financing of the sector. There is still some way to go. It may be that, like Germany, Japan, Luxembourg and the Netherlands, that a social‐insurance solution for funding of long‐term care must be pursued. The main national programs that deliver aged care in community and residential settings are: • The Home and Community Care program (HACC) • Community care package programs: Community Aged Care Packages (CACPs), Extended Aged Care at

Home (EACH) and Extended Aged Care at Home Dementia (EACH Dementia) • The Transition Care Program (TCP) • Programs for DVA clients, including Veterans’ Home Care and Community Nursing • Residential aged care (permanent and respite care) • The National Respite for Carers Program (NRCP). Currently overall spending on aged care services is relatively low, as a percentage of GDP compared to what is spent on acute care, and has not grown at the same rate as the acute sector. The issue of client directed funding is gaining momentum within Australia. CHA has provided support to the development of cash benefit programs such as the Home Assessment package, outlined in the CHA submission to the National Health and Hospitals Reform Commission in May 2008, and advocate that client directed models of care be introduced into the Australian Government’s Community Care Packages. The increasing burden of regulation of the residential aged care sector is meeting growing resistance within the sector, although Catholic service providers would not support a completely deregulated


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environment. The increased focus on regulation could come at the cost of measuring improvements in outcomes. Improvements in quality care may be difficult to sustain into the future due to the worsening workforce issues. In order to understand how Australia has arrived where we are in terms of aged care policy it is necessary to look retrospectively at how the current structural frameworks have emerged.

Chronology of Australian Aged Care Policy


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Long term trends in aged care policy development, as described by Kendig & Duckett (2002), have involved the following:

• The increasing involvement by government in responsibility for care of older people. • A shift from providers ‐ as the leaders in forming the structure of aged care, to government, as

funders. • Rising expectations and financial capacity of older people anticipating and requiring care. The

vast majority of older people can no longer be assumed to be economically disadvantaged. • Recognition of carers as central to aged care. • Real incomes will not continue to rise, and the overall availability of public resources will

decrease. • Population ageing will continue to increase.

Funding of aged care as a percentage of GDP

Australia’s Health 2008 (AIHW 2008) cites a recent study based on 2002–03 data (Vos et al. 2008) that estimates that total health expenditure will increase by 127% over the three decades between 2002–03 and 2032–33, from $71 billion to $162 billion (in constant prices)—an increase of $91 billion

Over the same period GDP is predicted to increase by 97%, so total health expenditure is projected to increase from 9.4% of GDP to 10.8%.

Residential aged care expenditure was expected to show the greatest growth (242% increase) over the three decades, mainly because of the ageing of the population in this period.

Table 1 Change in health and residential aged care expenditure for each area of expenditure, 2002–03 to 2032–33 (per cent)


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Demographics (Taken from Australian Institute of Health and Welfare, Australia’s Welfare No.8, and Australia’s Health No.11)

• On 30 June 2006, an estimated 2.7 million Australian residents were aged 65 years or over, more than half of whom were aged 65–74 years. Women accounted for a higher share of the very old (68% of people aged 85 years or over).

Table 2 Persons aged 65 years or over, 30 June 2006

• An increase in the growth in the older population as a share of total population will take place from 2011 onwards as surviving members of the baby‐boomer generation reach 65 years of age.

• This growth in the older population will have a direct effect on the provision of Australian Government‐funded aged care places ‐ planning targets are currently based on the size of the population aged 70 years and over.

• There has been a considerably higher rate of growth of the very old population accelerated from 2004 (Chart 1).

• The number of people aged 85 years or over doubled in the 15 years to 2006. • Over the next 40 years the number of people aged 85 years or over is projected to more than

quadruple to 1.6 million (Costello 2007).

Chart 1 Increase in number of people aged 65 years or over, 70 years or over and 85 years or over since 1996, 1997 to 2006

Source AIHW Australia’s Welfare No.8


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Indigenous Australians • In 2006 between 41,000 and 45,000 Aboriginal and Torres Strait Islander people were aged 50–64

years. • People aged 50 years or over accounted for around 11% of the total Indigenous population in 2006.

Culturally and Linguistically Diverse Populations (CALD) • People from CALD backgrounds accounted for 35% of all people aged 65 years or over on 30 June

2006. • Major birthplace countries of origin with higher median ages were Italy (66 years), Greece (64 years),

Germany (59 years) and the United Kingdom (54 years). • Older people from non‐English‐speaking countries account for around 21% of all older Australians

(581,200 people). Of these, 51,500 were aged 85 years or over. Older people from these countries make up 23% of the 65–74 year old population, and 15% of those aged 85 years or over.

Housing • Data from the 2001 Census estimate that around 94% of older people in 2006 lived in private

dwellings as members of family, group and lone‐person households. • Just over 6% were usual residents in non‐private dwellings, which include hotels, motels, guest

houses, independent living units in retirement villages, and cared accommodation such as hospitals, aged care homes and supported accommodation offered by some retirement villages.

• Approximately 29% of older people live alone in private dwellings. • 39% of people aged 85 years or over living in one‐person households. The likelihood of living alone

increases with age. • In the next 15 years, significantly more older people will be living alone in private dwellings, with a

projected increase from around 783,000 in 2006 to 1.3 million in 2021, 70% of whom will be women. • 1% of people 65–74 years, 7% of people 75–84 years, 31% of people aged 85 years or over lived in

care accommodation in 2003. • On 30 June 2006, 145,175 people aged 65 years or over were permanent residents in residential aged

care facilities, more than half of whom were aged 85 years or older.

Workforce • Australia faces a potential shortfall of 195,000 workers over the 5 year period from 2004–05 to 2009–

10 as a result of population ageing.

Retirement income • In 2004–05, around 44% of fully retired people retired with a government pension or benefit as their

main source of income. • Superannuation was the main source of income at the time of retirement for 12% of retired people. • Two‐thirds of retirees relied on a government pension or benefit as their main source of income.

Access to Government funded aged and community care • 202,502 people received permanent residential care during 2006‐07 equivalent to 10.6 per cent of

people aged 70 years or over (as at 30 June 2006 from 2006 ABS Census) • 38,806 people received residential respite care during 2006‐07 equivalent to 2.0 per cent of people

aged 70 years or over (as at 30 June 2006 from 2006 ABS Census) ‐ of whom 17,932 were later admitted to permanent care

• 55,373 people received care through a community care place (either a Community Aged Care Package, an Extended Aged Care at Home package or Extended Aged Care at Home Dementia package) during 2006‐07 ‐ equivalent to 2.9 per cent of people aged 70 years or over (as at 30 June 2006 from 2006 ABS Census) ‐ including some who also received permanent or respite residential care during the year

• 6,511 people received care under the Transition Care Program during 2006‐07. • In addition, an estimated 777,470 people received services through the Home and Community Care

(HACC) program, of whom 67 per cent were aged 70 years or over.


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International Experience of Aged Care The Organisation for Economic Cooperation and Development (OECD) countries, of which Australia is a member, have adopted different arrangements to finance and provide long‐term care services for the elderly. All systems however essentially respond to common system objectives of:

• improving quality • ensuring affordability and access to care • enhancing patient orientation • maintaining financial sustainability • promoting value from money

Most comparable systems to Australia that provide care for the elderly are highly decentralised with systems of transfers from the central government to supplement local funding. Very few countries apart from Germany and Japan, have chosen to develop a specific social insurance program of care for the dependent elderly. Some countries have organised their aged care services in such a way that needs can be met without social insurance. Internationally the most recent reforms have accentuated the devolution of responsibilities to the local level. The central government concentrates on overall guidance and accreditation, leaving to decentralised authorities the task of determining the real needs of their communities. (Jacobzone. S: 1999).

Aged care in OECD countries (Taken from The OECD Heath Project: 2005: Long‐term Care for Older People) • The vast majority of primary caregivers who are family members occurs in Australia, Finland,

Germany, Japan, the Netherlands, New Zealand, Sweden, the United Kingdom, and the United States. Only in Denmark are paid home care workers a major source of primary caregivers, but in most cases the family is the primary caregiver. In the United States in 1994, 94% of all disabled elderly in the community received at least some informal care.

• In England, most caregivers are women, as in the United States; however, caregivers appear more likely to be under the age of 65 than in the United States. Most elderly in Japan live with their sons (if possible) and care of elderly disabled persons is traditionally the responsibility of the daughter‐in‐law.

• Among the countries providing formal respite services are Australia, Germany, the United Kingdom, and the United States. As part of the German social insurance program for long‐term care, informal caregivers who provide a substantial amount of informal care are entitled to up to four weeks of respite care).

• In summary Austria, Germany, Japan, Luxemburg, the Netherlands, Norway and Sweden– provide comprehensive coverage, treating long‐term care in broadly the same way as they treat other health‐related needs in their social protection system. The share of GDP spent on publicly financed long‐term care varies from 0.8% to 2.9% in these countries.

• Most other OECD countries provide a system for long‐term care that depends in part or in whole on a means‐test of the user’s income and/or assets. In these countries, the share of GDP devoted to public spending on long‐term care varies from below 0.2% to 1.5%.

• Australia sits below average in the amount of public expenditure spent on long term care, in both public and private expenditure.


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Table 3 Public and private expenditure on long‐term care as a percentage of GDP, 2000

Source: OECD 2005

• The Netherlands introduced universal funding for long‐term care as part of their health insurance system in1968. It has been modified several times, most recently in 2003 in that all home‐care users now have the option of a payment in cash to purchase their own care.

• Hungary and Korea are thinking about introducing long‐term care insurance in the future.

• Ireland have recently held an independent review recommending the introduction of a form of public long‐term care insurance, and the government has been considering various options (Sutherland :2008).

Recent international innovations in public programs for long term care

Austria introduced a tax‐funded system of long‐term care allowances in 1993, payable in cash only, with the amounts determined by assessment of recipients on a seven‐point scale by the type of care and number of hours of care needed. The care allowances were funded from general taxation as part of the same reform package, the level of contributions to health insurance was increased by 0.8% for self‐ employed persons and farmers and by 0.5% for retired people.

In Germany a public scheme of long‐term care insurance was introduced in 1995‐96. It comprises a mandatory public scheme, currently covering just over 70 million people, and a private insurance scheme, currently covering around 8.5 million people. The scheme is administered by health insurance funds while the private scheme is administered by private insurers according to federal regulations. Contributions to the public scheme, from retired as well as working‐age people, are set at 1.7% of gross income, up to a maximum contribution, with employers usually paying 50% while the individual pays the other 50%. Contributions to private long‐term care insurance are age‐related and subject to federal regulation.

In Germany there is a growing gap between the cost of services in the long‐term care market and payments per care level, which have been kept fixed since the introduction of the system and not been adjusted for price increases. In addition the annual increases in revenues under the fixed contribution rate have since 1998 been for all but one year substantially lower than the growth of expenditure, in particular due to the spending pressures from care in institutions. So most interestingly following a ruling of the Federal Constitutional Court that called for different contribution rates for employees with and without children, the individual contribution rates for the latter have in 2005 been raised from 0.85% to 1.15%.

The Luxembourg social insurance system is funded 45% from general taxation with a 1% individual contribution based on salary or pension (around 35% of funding in 2001). The remainder is funded from a special tax on electricity bills. The new insurance scheme provides both benefits in cash and in kind to cover the cost of care at home or in an institution. What has occurred since this introduction is a a significant shift in the balance of care between 2001 and 2004, with a larger share of care recipients now being cared for at home rather than in an institution.

Japan introduced public long‐term care insurance in 2000, funded 50% from general taxation (shared between central and sub‐national governments), 32% from contributions from employees and 18% from contributions from pensioners. Contributions are graduated by income, up to a maximum, and social


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assistance funds subsidise the contributions of those on the lowest incomes. Long‐term care insurance is currently restricted to people aged 40 and older. All benefits are paid according to a national scale and are received as an equivalent amount of services. The user pays 10% of the cost of services. The new system has led to an increase in the range of services offered to older Japanese.

Consumer Directed Care (CDC)

Taken from the study by Tilly & Rees (2007) various types of international studies have been undertaken in relation to Consumer Directed Care. Outcomes of this research include: • 65% percent of Austrians who received a cash allowance reported that it improved independence,

choice and control in their lives. • In Germany, 76% of beneficiaries chose to receive their benefit in cash, despite the fact that the

value of the cash benefit was half that of the benefit available through agencies. 43% percent of beneficiaries reported quality care had improved as a result of the funding model. 55% said that quality remained the same.

• In the Netherlands 85% of participants who received cash had the ability to choose and control their services, while only 46% of those relying on agencies could do so.

• A study in California showed that those who directed their own services reported more satisfaction with their services, higher quality of care, and better well‐being than those who relied on agency services.

• Another US study used a randomised‐controlled trial to test the outcomes of CDC programs in three states. The study found that elderly and non‐elderly participants who managed their own services had fewer unmet needs for care, and reported more satisfaction with their care and quality of life than participants who relied on agency services. This group also reported the same or significantly fewer adverse health outcomes (Foster L, et al: 2005)

• In Arkansas , CDC participants had significantly less use of nursing homes over a three‐year time period than those who relied on agency services (Dale SB, Brown R : 2006).

Summary

• All of these OECD reforms have been supported by: o additional contributions o ensuring none of the schemes puts all of the burden onto the working population o contributions from pensioners

• All of the schemes used the expertise of existing agents for health insurance or social services in their implementation

• Introducing a comprehensive public scheme does not have to be at the expense of reducing the coverage of private long‐term care insurance

• In Germany, the market for voluntary complementary long‐term care insurance, to meet additional costs not covered by the public scheme, has grown alongside the establishment of the public long‐term care system

• Some countries have been prepared to raise additional taxes or social insurance contributions specifically to finance a new benefit for long‐term

• In some countries a number of options for further reform are currently being discussed, such as improving prevention and rehabilitation strategies and broadening the contribution base, e.g. by seeking substantial additional contributions from pensioners in particular.

• Countries such as the United Kingdom and Sweden who, like Australia, have funded services from general taxation have faced difficult choices, such as reducing the scope of services while targeting services toward the more sick and disabled person. Sweden, for example, has tightened their means‐testing.

• Private long‐term care insurance as primary cover has played a very limited role in most OECD countries. However, private insurance might play a role in the future to meet additional costs not covered by public programs. This type of complementary insurance becomes more affordable when the public system covers the first component of the cost.


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Consumer Directed Care Programs Would aged care service consumers in Australia see value in increasing consumer choice through the provision of cash or vouchers instead of direct funding to services? The objective of Consumer Directed Care is to provide people who require care, and their carers more choice and control over their care than they have with current agency programs. Consumers are able to choose which services they receive and who will deliver these services and when. Interest in consumer directed care in the aged care sector is growing, with Alzheimers Australia, Aged and Community Services Australia (ACSA) and the Brotherhood of St Laurence all producing research in this area. Alzheimer’s Australia has put forward options within which greater consumer choice may be facilitated. (Tilly. J., Rees. G.: 2007) According to Alzheimer’s Australia international studies of these programs have shown that:

• Participants and their carers have better outcomes related to quality of life, independence and satisfaction with care, than those who rely on home care agencies.

• Quality of care is at least as good in these types of programs as it is in traditional programs. • There is no systematic evidence of abuse or neglect of consumers who participate in these

programs. Consumer Directed Care programs have been well researched overseas, as detailed in the international environmental scan, and results have been positive. Interesting ideas that explore how Consumer Directed Care funding could apply within Australia can be found in Is Consumer Directed Care a direction for Australia?, written by Dr Anna L Howe PhD, Consultant Gerontologist. Dr Howe argues that the Consumer Directed Care model may affect quality of care as Consumer Directed Care could reduce or eliminate the need for home care agencies and case managers – this may lead to issues of inferior service quality. Passing the formal responsibilities for managing care to family members of older people, Dr Howe argues, may simply add to the strains they already experience. There are also limitations for those who do not have a close family member as a carer. It could be argued that there may be a possible shift in responsibility for outcomes of community care programs from government and providers to clients and carers. It could equally be argued that this form of funding provides for more flexible service delivery than is offered now, and one that is controlled by the consumer. Consumer Directed Care is one option among many when investigating innovations in community care in Australia, and CHA is of the opinion that it warrants further exploration.

Population Based Funding The implementation of a population health focus that would require a fundamental shift in health systems processes and priorities.

Planning for defined geographical populations across metropolitan, regional, rural and remote areas would create challenges for government, but if there is a single funder as a result of the National Health & Hospitals Reform Commission then this task becomes easier. CHA believes the Australian Health Care Agreements could be used as a lever to deliver this outcome. Alternatively functional re‐organisation of commonwealth/state responsibilities for community based care could also occur.


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A population approach to health funding will facilitate equitable access to aged care services, as well as health care services. By establishing indicators of need across regions allows for greater flexibility and responsiveness in service delivery. There is a caveat though, internationally there is mixed evidence about the cost‐efficiency of integrating funding structures for aged care services at the local level and as well about the benefits of explicit case‐management. Further research is required.


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Next Steps The CHA Blueprint incorporates proposals for specific initiatives as well as changes to the ways Government and providers manage aged care services. The outcomes of these initiatives, if implemented, will achieve the CHA Aged Care Vision of equity of access to aged care services, for all Australians, with a preference for the socio‐economically disadvantaged. Three broad goals have been established as a basis for implementing the CHA Aged Care Policy Blueprint:

1. Older Australians receive the care they need in the accommodation of their choice, whether in their own home, in the community or residential facility

2. That demographic based funding will be oriented to ensure the delivery of excellence in person centred, compassionate care.

3. That the funding framework for aged care will ensure that the care of older Australians is delivered by an appropriately skilled and qualified workforce.

These goals are not exhaustive. They provide a framework within which solutions, policies, initiatives and programs can be developed and implemented. These goals encourage a targeted process of implementation and provide a means to measure the progress of the CHA Aged Care Policy Blueprint over time.

CHA 2020 Vision Plan for Aged Care 1. Older Australians receive the care they need in the accommodation of their choice, whether in their own home, in the community or residential facility.

1.1 Population based planning 1.1.1 Planning for aged care services is reflective of current population projections. Projections for planning regions must be reviewed and re‐modelled regularly as more timely data in relation to demand and demographics are available.

1.2 Informal Care 1.2.1 Informal care is supported and encouraged through appropriate levels of income support, flexible employment options, adequate respite services and through the taxation system.

1.2.2 Vocational qualifications are established that support the experience of carers.

1.3 Accessing Care 1.3.1 Implementation of a fully Commonwealth funded national entry and access assessment service. This service would comprise multi‐disciplinary teams, located according to revised planning regions (see 1.1.1).

1.3.2 Consumers access benchmarks that measure government and service provider performance.


2.1. Equitable Access 2.1.1 A single, simplified and consistently applied national aged care program, in order to receive the right care, in the right place, at the right time.


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2.1.2 Regular assessment of unmet need by planning regions.

2.1.3 The establishment of a Health and Aged Care Access Ombudsman to examine and review complaints regarding access to aged care services.

2.2 Person Centred 2.2.1 Funding and quality monitoring systems rewards and enhances the capacity of aged care services to deliver person centred care.

2.2.2 Creation of an innovation fund that promotes a leading edge approach to person centred aged care, and ensures the dissemination of this research.

2.2.3 Extend the existing schools chaplaincy program to also sponsor the provision of pastoral care services in community and residential aged care by providing annual service grants in support of pastoral care programs.


3.1 Coordination 3.1.1 Establishment of a National Health Workforce Commission that consolidates all current initiatives aimed at the health workforce planning and development.

3.2 Licensing and Competency 3.2.1 All aged care workers have completed a minimum competency based training program, and are licensed under a national regulatory system.

3.3 Scope of Practice 3.3.1 Broaden scope of practice to reflect consumer needs and workforce availability.

3.4 Workforce Support 3.4.1 Support provided to ensure access to continuing education initiatives. This will assist in the recruitment and retention of aged care workers.

3.5 Palliative Care 3.5.1 All aged care workers have completed a minimum competency based training program in the provision of a palliative care approach in Residential Aged Care.

3.5.2 That pain assessment and management, symptom management, end of life care, support of and communication with the family, grief and bereavement support and advanced care planning be incorporated into a review of the Aged Care Standards and quality monitoring processes.


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Implementation 2008 ‐ 2011 The Implementation 2008‐2011 strategy represents the current cycle of proposed initiatives within the three goal areas and will be used to track the progress of these recommendations against industry and government.

1. Older Australians receive the care they need in the accommodation of their choice, whether in their own home, in the community or residential facility.

Priorities Actions Industry Government

Carers In recognition that most of the care that is provided to older people is currently provided by family members, greater support needs to be provided to carers. Types of support includes access to information, resources and self help groups; greater flexibility in the workplace; financial support; and flexible respite care

Nationally managed consistent and timely eligibility assessment process ‐ CHA recommend redefining the role and management of ACATs. ACATs should be managed centrally, by the Australian Government, to ensure consistency of eligibility is applied, and that there is no conflict of interest when undertaking assessments

Access and Entry Points to Aged Care Services

Visibility ‐ Families require pathways that are easily accessed and followed in times of crisis

Consumer Directed Care Models

CHA recommend trialling Consumer Directed Care models, where there is the potential to offer aged care service users much greater choice – through enabling them to decide how a care budget or allowance should be spent. Types of options that could be piloted include: o Personal budgets and consumer directed

employment of care assistants o Payments to the person needing care who can spend

it however they like, but must ensure they acquire sufficient care

o Payments to informal care givers as income support

The Aged Care sector requires an invigoration of research and development. CHA supports an evidence‐based approach as to what works well in aged care. It should be acknowledged that it is difficult for a sector to be innovative, unless it is resourced to be. Research, as we know, can help to shape ideas on policy directions.

Research

CHA also recommends that there be a focus on the social determinants of health and a whole of government response to them in order to assist in the development of policies in areas other than health which will have an impact on healthy ageing. This may include analysing the impact of the physical environment on people as they grow older, including housing and environmental issues, and understanding how people manage and spend their time post retirement. This is all with the aim to deliver services within a structure that is designed flexibly.


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CHA recommends that the existing Community Care programs, that is, Australian Government and State and Territory funded Home and Community Care Programs and the Australian Government funded package programs be rationalised to eliminate duplication and overlap. This would provide a more seamless range of support that would enable people to remain in their own home for longer as their dependency levels increase

The ability of future retirees to fund their aged care service needs is likely to be directed by the availability of funds at their disposal. Superannuation should be increased to its originally proposed 15%, with consideration to be given to the quarantining of a portion of superannuation payouts to be available specifically for purchase of aged care services.

CHA further recommends developing insurance products to enable self‐funding of aged care services in a manner similar to self funding of health care by way of the operation of private health insurance.

Equity of Access to Community Care Services

CHA recommends that unmet need for HACC services is quantified, particularly to inform the development of new funding models.

Regulation CHA would advocate that existing planning and allocation systems should be abolished and that ACATs be managed by the Australian government. ACATs would then assess eligibility for a subsidy. This eligibility and subsidy should then be transportable and follow the consumer. This approach would assist in the implementation of consumer directed care models for the Australian Government subsidised Community Care Packages

Building certification, introduced in 1997, only serve to replicate the Building Code of Australia Standards. The two criteria that do not replicate the standards – privacy and space requirements – could and should be dealt within other quality frameworks.

To grow capital investment, providers should be allowed to publish bed rental amounts and provide consumers with the choice of either a daily charge or a refundable lump sum. The current disparity between who is charged an accommodation bond and who is not creates perverse incentives. A bed rental scheme addresses this issue with the government providing funding for an acceptable minimum standard, hence ensuring the socio‐economically are not disadvantaged. It also offers greater flexibility and choice


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The distinction between low and high care be abolished, enabling bonds to be raised across all residential aged care settings.

Funding Cost growth is exceeding subsidies and most productivity gains flow through to improvements in the quality of care rather than act as an offset to increasing costs. The creation of a new funding regime is recommended, that can provide appropriate levels of care for a person and meets their cost of care


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Competencies CHA supports clear articulation of the standards of professional and technical competence in aged care health professionals through the development and improvement of the application of competency models within aged care –particularly in the areas of skills, experience and knowledge required. Competency assessments could provide a more consistent national approach to workforce.

Innovation Within the aged care sector development of tools, guidelines and frameworks for aged care workforce innovation, accompanied by an evaluation framework is recommended. Government should be responsible for the development of incentives to progress to more responsive service models within aged care

National Workforce Commission

In order to address the fragmented planning processes, CHA recommend that a National Workforce Commission be established to bring together all planning processes – from education through to the coalface. In the first instance CHA requests that the National Health Workforce Taskforce (NHWT) National Health Workforce Planning Tool be broadened. At the moment modelling on the demand side only captures hospital separations and Medicare data at the aggregate level. It must be broadened to the primary care sector, which should include aged care services delivered in the community and residential aged care.

Palliative Care That pain assessment and management, symptom management, end of life care, support of and communication with the family, grief and bereavement support and advanced care planning be incorporated into a review of the Aged Care Standards and quality monitoring processes.

Pastoral Care Pastoral carers and Chaplains make a valuable contribution to the spiritual and emotional wellbeing of residents in residential aged care. A government sponsored program could support the spiritual well being of residents as well as provide pastoral care and enhance engagement with the broader community. The objectives of such a program would be to provide greater pastoral care, general religious and personal advice and comfort to all aged care residents


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REFERENCES Australian Government; The Treasury; Intergenerational Report 2007, http://www.treasury.gov.au/igr/IGR2007.asp, accessed 4 August 2008.

Australian Institute of Health & Welfare (2007) Australia’s Welfare No.8, 82‐83

Australian Institute of Health & Welfare (2008) Australia’s Health No.11

Dale SB, Brown R, “Reducing Nursing Home Use Through Consumer‐Directed Personal Care Services,” Medical Care, vol.44, no.8, August 2006

Foster L, et al, Effects of Consumer Direction on Adults’ Personal Care and Well‐Being in Arkansas, New Jersey, and Florida, USDHHS, ASPE, Washington DC May 2005

GaÈtan Lafortune, GaÎlle Balestat, and the Disability Study Expert Group Members: March 2007: OECD Health Working Papers No. 26 Trends In Severe Disability Among Elderly People: Assessing The Evidence In 12 OECD Countries And The Future Implications Grant Thornton Aged Care Survey 2008, summary findings October 2008

Hogan, W.P. (2007) ‘The Organisation of Residential Aged Care for an Ageing Population’, Papers in Health and Ageing (1), The Centre for Independent Studies Policy Monograph 76, Sydney

Kendig, H., Duckett, S.J., (2001) ‘Australian Directions in Aged Care: the Generation of Policies for Generations of Older People’, Australian Health Policy Institute Commissioned Paper Series 2001/05, 4‐5,

Productivity Commission 2008, ‘Trends in Aged Care Services: some implications’, Commission Research Paper, Canberra

Stephane Jacobzone (1999) Labour Market And Social Policy ‐ Occasional Papers N°38 :Ageing And Care For Frail Elderly Persons: An Overview Of International Perspectives

Sutherland.S., : April 2008: Independent Review of Free Personal and Nursing Care in Scotland: A Report by Lord Sutherland: Scottish Government, Edinburgh

Tilly. J., Rees. G.: 2007: Consumer‐Directed Care: A Way to Empower Consumers?: Alzheimer’s Australia Paper 11, May 2007

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