Editorial

Aged care, ethics and public policy

Michael Fine
Department of Sociology and Centre for Research on Social Inclusion, Macquarie University, NSW

PP: 109 - 112

Article Text

Aged care has long held a rather ambivalent position alongside, yet also as part of, the health care system in Australia and New Zealand, as it has in comparable countries of North America and Western Europe. This relationship is under pressure at the present time as there is a search for new constellations of care which link acute care hospitals more closely to ongoing residential aged care and care provided at home. Although established as an alternative form of provision, it is becoming increasingly popular to regard aged care as a form of complementary service for which ever closer linkages with more expensive, institutionally based and professionalised medical services are sought in order to produce what is often described as continuity of care (Glendinning, ed, 1998). Yet this search to link long-term aged and acute care into a seamless, integrated system comes, paradoxically, at a time of pressures in the field of aged care to reduce costs and make it increasingly self-funding. As aged care is subjected to the principles of user pays and to the demands to provide low-cost substitute services for other areas of the health system, it is becoming ever more difficult to maintain basic care for its primary target group.

The undeniable growth in the awareness of the public and the interest in ageing issues that has unfolded in recent years in advanced western societies has been accompanied by a crisis over the funding of the welfare state, which has led to major reforms in the system of public pensions and retirement income (Phillipson, 1998). The pressures on aged care, in all its forms, have been greater still. This is a matter that should be of concern not just to older people and their families, but to all nurses and other health professionals. Now that the linkages between aged and acute care services are becoming increasingly significant, problems in the field of aged care can no longer be regarded as self-contained. Increasingly, they have a flow on effect which ensures that problems in aged care are likely to have a direct effect on acute care services, as well as on the lives of those who provide unpaid care as family carers, often at the double expense of giving up paid employment.

Three transformations

In Australia, aged care underwent its first major postwar transformation when a series of privately owned step-down residential cum nursing services that became known as convalescent or nursing homes were established in a fairly haphazard manner in the 1950s and 60s (Fine and Stevens, 1998). Their purpose was to provide care to the large numbers of the chronically ill older people discharged from, or refused admission to, the newly emerging acute care hospitals of the postwar period. A second period of transformation took place in the last two decades of the twentieth century, as aged care became a site of significant innovation. Developments in the field of aged care in Australia and New Zealand parallelled and in some cases led those taking place elsewhere in the world, as the field was transformed from a system of backward looking 'Cinderella services', to become what European researchers came to describe as the 'cutting edge of change' (Baldock & Evers, 1992). Under powerful fiscal as well as demographic pressures, a range of alternative forms of community care services were developed, interesting multi-disciplinary assessment teams were introduced to help stem the flow of residents to nursing homes, and new forms of care and care organisation, of which perhaps the most significant has been case management in all its forms and varieties, were introduced. Where there had once been a sharp divide between formal and informal care, new forms of partnership began to emerge, with family carers, almost three in every four of whom are women, increasingly supported by formal services and/or direct carer payments (Glendinning & McLauglin, 1993).

Like residential aged care before it, this second period of postwar aged care, based on the philosophy of community care, developed very much as an alternative set of provisions, with some links to, but largely set apart from, acute care services. The intention was to provide those who needed help with a 'choice' to remain in their own home, supported by formal community services as well as by informal care. As most services were highly specialised (home nursing, meals on wheels, home care or housekeeping, day care, etc) the division of labour generally requires coordination between specialised organisations and, in the home, between the assistance provided by formal organisations and that of informal caregivers. This means problems of coordination have been built into the new designs for aged care (Fine, 1999).

Problems of quality, too, continued to be experienced far too frequently in aged care, especially in the residential care system. As the media's regular recycling of sensationalised tales of abuse in care suggest, these have proven particularly prevalent in nursing home settings, where high levels of client dependency combine with under-funding, poor levels of professionally trained staff and, some accounts suggest, the profit motive to produce conditions which systemic failures are only likely (SWAG, 1982; Senate Select Committee, 1986; Ronalds, 1989; Gray, 2001).

A third period of transformation now appears to be under way, as developments in the field of acute care have led to attempts to seek solutions by using long-term care services as cheaper substitutes, through the creation of an 'integrated' system of coordinate care. With this, the separate character of aged care services and the problems experienced with coordination have been intensified. As Bates and Lapsley (1985) have argued, the health systems of most advanced economies experience ongoing pressures as a result of the continual inventiveness and expansion of health services that takes place within a broadly public financed and regulated system. These pressures are felt most strongly in the acute care setting of the hospital, where life saving and life changing medical interventions, such as open heart surgery, use of intensive care and the implantation of artificial hips and other joints, that only a few years ago were regarded as medical miracles, are now available on a routine basis. Medical advances and the associated professional differentiation and specialisation that flow from this are continually expanding the capabilities of the system to intervene. This requires continual readjustments and restructuring in the acute care sector if the system is to continue to operate within limited public resources, compounding the difficulty facing all human services in the new post-industrial economic order. As Iversen and Wren (1998) argue, human services suffer from an inability to achieve direct productivity increases comparable to that in the manufacturing or financial services sector, leading to a constant need to restructure and reorganise.

Policy implications

The consequences of this ongoing restructuring and reorganisation of acute health services are many, as attempts to provide new treatments and forms of intervention require constant pruning-back and restriction of those pre-existing range of treatments. For example, shortened length of stay in hospital, one of the most common solutions, requires earlier discharge and, ideally, ongoing care outside the hospital, for which both community-based and residential care are commonly sought. Attempts such as these to substitute low intensity, lower cost aged care for expensive, publicly funded acute hospital care is where the financial problems of the acute care system run up against the coordination and quality issues affecting aged care.

Rather than more intensive linkages between the two systems providing simple solutions to the need for continuity of care, as some health care planners ague, the exercise has considerable potential to simply aggravate the existing problems in aged care. Here, in contrast to the public funding strategies of the acute health care system, selective but increasing reliance on user payments for care are found. These also interact with the complex funding and administrative arrangements of aged care, such as the casemix payment system, the RCS or Resident Classification Scale adopted in Australia (Gray, 2000), which are predicated on a completely different pattern of service use than that found in acute care.

Ethics and finance

One expression of the impasse with which we are likely to be increasingly confronted are the ethical pressures being placed on older people in both the acute care and aged care settings. In acute care, the use of scarce resources by older people is all too often regarded as unnecessary, perhaps even selfish, while those older people who remain a longer time in a hospital bed are considered 'bed blockers'. Aged care, too, long a victim of poor public funding, is increasingly requiring more financial contributions from service users. The dubious ethical argument, that public support for the elderly comes at the cost of younger generations and should be reigned in, has been eloquently articulated by the New Zealand author, David Thomson (1993), finding resonance in Australia in the Howard Government's National Commission of Audit (NCA, 1996) which recommended the adoption of additional user pays principles for aged care to counter this ethical problem.

At the heart of this ethical dilemma, however, lies the question of finances. A more ethical way around many of the financial problems that deserves to be considered far more extensively is the introduction of a system of social or public insurance that would ensure future users of services paid for their aged care (McCallum, 1999), but spread the risk around between a large pool of likely users over a prolonged period of time. Private insurance for aged care has not proven successful, as few people regard the extra expense worthwhile at an early age. Those who do take out private policies are likely to be those at high health risks (Glennester, 1996). Experience with public insurance for long-term care in the Netherlands, Germany, Israel and, most recently, Japan, has shown it to be extremely popular and to provide the underpinnings for a more financially viable and ethically equitable system than is possible with a user-pays system (Fine and Chalmers, 2000).

Any program of long-term care insurance should not, however, be separate from existing schemes for national health insurance, but be linked to it, to prevent problems of cost-shifting arising, as experience in the Netherlands has shown. The system might also draw on the positive appeal that contributions to extended care insurance has for people as they grow older, as has been the case in the Japan, where only those aged forty or over are required to pay.

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