Creating a national community aged care system – Moving beyond individualised funding
The proposed merger of the Commonwealth Home Support Program (CHSP) or Home and Community Care (HACC) and the Home Care Packages (HCP) program in 2018 poses significant risks for older people and their allies, providers and government. For the last 30 years, program based or block funding (through HACC & CHSP) has played a key role in supporting older people and their allies to age well in their community. In contrast, individualised budgets and consumer-directed care is relatively new, being introduced in 2013. In the race to personalise or individualise community care for older people and their allies in Australia, there is a risk that the capacity building initiatives developed from block or program-based funding for older people and their allies may be lost.
Individualised funding – one mechanism for personalising community care
The community aged care system in Australia is undergoing radical change as part of personalisation approaches embedding the concepts of choice and control for service users in policy design. Personalisation refers to mechanisms that aim to modify services to meet the unique circumstances of people who use social care services. Personalisation and choice and control for older people in community care have largely been introduced through individualised budgets. However, the degree to which this has improved the choices of people using home care packages is contested with some anecdotal evidence of people getting less support and people not understanding their individualised budget. Additionally, research from the UK has shown that many older people report lower levels of control than younger people with disability under an individualised budget system. The research indicates that older people and their carers may need more independent support in an individualised funding system..
In the race to embed concepts of choice and control for older people in the redesign of the community care system, policymakers have forgotten there are a range of policy mechanisms that can be used to increase the choice, control and agency of service users. Other mechanisms may include person-centred planning, services providing one-to-one flexible support, more personalised intensive support (support facilitation or case management), people managing their own supports (often referred to as self-directed support) and capacity building initiatives to build the skills and knowledge of people using the system. All of these mechanisms could be considered to embed choice and control for older people and their allies in a merged national community aged care program.
Reflecting on history
The creation of the HACC program aimed to bring together seven different systems of community aged care operating in Australia. Prior to this, State governments had some provisions for community care for older people in the 1950s and 1960s (including home nursing, delivered meals, domiciliary care and allied health); however, there were differences between the various state and territory program that led to inequities in access for older people. These factors and the recommendations to expand community care for older people made by government inquiries between 1975 and 1985 led to the creation of the national Home and Community Care (HACC) program. Differences between states and territories continue to exist; for example, NSW has the largest number of service outlets while local government remains a large provider in Victoria. The differences between state and territory HACC and CHSP service systems is an important reason to carefully debate the costs and benefits of a merged national community aged care program.
The creation of the HACC program revolutionised how older people and their carers were supported in Australia. Since 1985, millions of older people, people with disability and their carers have lived in their community through support from program-based funding, enabled by significant growth in funding from government over its 30-year history. Furthermore, some of the social support programs have built connections between people and promoted the social inclusion and connection of older people into the community, particularly people from culturally and linguistically diverse backgrounds and Aboriginal and Torres Strait Islander people. In this sense it has created an entry point for people to access support, particularly for some people who historically may not have been willing to access more traditional in-home support. Additionally, more recent initiatives (through ideas of wellness and active ageing) have built social capital and supported older people and their carers or allies to age well in their communities.
The weaknesses of the HACC or CHSP program, particularly for older people and their allies, have been well documented. The structure of the program through service types led to the creation of a complex system that was difficult to access. There was significant duplication in services with some competitive funding processes creating fragmented service systems. The funding of service types led to rigidity in how services were delivered with some older people needing more support than was available. However, the creation of a central gateway through My Aged Care may address some of the access issues despite the significant challenges in its implementation.
Key principles for a national system
The merging of the CHSP and HCP program is an opportunity to create an integrated and seamless system for older people and their allies. Building on the rich history of diversity of the community aged care system, it is vital to consider how program and individualised funding can empower older people and their allies to age well in their communities. There are a number of principles that should be considered in the redesign of the community aged care system.
Firstly, if individualised funding is one mechanism that is being considered in CHSP, government and stakeholders must critically review the research and evidence (particularly from the UK) on the individualisation of funding for older people and their allies. Research highlights that individualised budgets for older people don’t necessarily increase their sense of choice and control. Furthermore, it requires significant cultural change for staff working with older people, as well as capacity building initiatives for older people and their allies to make individualised funding systems work. If the individualisation of funding is being considered for some components of CHSP funding (such as allied health or respite for carers) it is important to test the ideas before they are rolled out across the system. In evaluating the impact of any changes, independent evaluation and review from appropriate academic institutions, is a critical tool to inform policy directions in Australia.
Secondly, there needs to be extensive consultation with different actors in the community aged care system, using a ground-up and top-down approach to consultation. As part of this conversation, consultations should be broader than meeting with the National Aged Care Alliance to canvas more diverse perspectives from across Australia such as with a range of consumer organisations working with older people, organisations working with Aboriginal and Torres Strait Islander people as well as regional networks across Australia. From these conversations, a set of principles could be developed upon which any reform or change should be based. This means that the current timetable for a merged program by July 2018 needs to be revised to enable appropriate consultation and debate.
Thirdly, it is important to consider whether the current funding models that operate in community care are fit for purpose. For example, the current four levels of packages in Home Care Packages could be redesigned. The Aged Care Financing Authority Fourth report on the Funding and Financing of the aged care sector identifies lower occupancy levels for Level 1 and Level 2 packages than Level 3 and Level 4 packages. If funding is truly attached to the individual and is portable, it may be the time to dismantle the existing packaged care system and attach funding to support plans, similar to the model currently being implemented through the National Disability Insurance Scheme (NDIS). This could be supported by core program-based funding allocated at regional levels to provide support to older people and their allies to build connections, wellness and active ageing in their local communities. As part of this, it is important to consider how to guarantee funding and how growth funding will be allocated.
Fourthly, any changes need to respect the diversity of the different systems operating across states and territories while balancing consistency across Australia. This diversity is also an opportunity to experiment with different types of personalisation at either a state or local level moving beyond individualised funding. Additional funding to kick start or explore different ways of working is important to encourage services and older people to develop more collaborative ways of working. The CHSP sector has a long history of collaborative practice and innovation and could test different approaches to personalisation in different regions of Australia.
Moving beyond individualised funding
History matters. The CHSP or HACC program has a long history of program funding that has supported a wide range of older people and their allies to age well in their communities. In the race to personalise community care through using individualised funding, the role of program-based funding in building social capital and connections between older people and their local community could be lost. Program based funding can exist with individualised funding to empower older people and their allies to age well in their community.
 KPMG (2015), Formative Evaluation of the Home Care Packages, Australia: Department of Social Services
 Netten, A., Jones, K., Knapp, M., Fernandez, J. L., Challis, D., Glendinning, C., . . . Wilberforce, M. (2011). Personalisation through Individual Budgets: Does It Work and for Whom? British Journal of Social Work. doi: 10.1093/bjsw/bcr159
 Social Welfare Commission,(1975), Care of the Aged Social Welfare Commission. Canberra, Social Welfare Commission
 House of Representatives Standing Committee on Expenditure (1982), In a Home or At Home: Accommodation and Care for the Aged, House of Representatives Standing Committee on Expenditure, Canberra, Australian Government Publishing Service
 Glendinning, C., Challis, D., Fernández, J., Jacobs, S., Jones, K., Knapp, K., . . . Wilberforce, M. (2008). Evaluation of the Individual Budgets Pilot Program York: Social Policy Research Unit