Review of literature
Concept of 'community care'
It is true that the movement from 'Institutional Care' to 'Community Care' has been a world trend in aged care policy since 1980s. In Australia, after introducing the Home and Community Care Act in 1985, the Commonwealth government has promoted 'community care' and increased the budget dramatically. The concept of 'community care' in the Home and Community Care Program is for elderly people to remain living in their own homes and for improving the quality of life for elderly people and their carers.
There are some arguments about the concept of 'community care' in the literature. Michael Fine (1995) maintains that there are some confusions in a range of terminology such as 'community care', 'care in the community', 'community support', and 'domiciliary care'. The fundamental characteristic of community care policies are dependent on the variable features which policies of the services are implemented.
The concept of 'community care' has often been regarded as an alternative to 'institutional care'. Anna Howe (1981:179) denies this and states that ﾒUnderlying the idea is the implication that a choice between institutional care and home care does exist and that both are available. For many of the aged, however, there is no real choice; it is a question of some minimal domiciliary support or nothingﾓ. Joan Higgins (1989) argues that much of what is termed community care actually takes place in institutions of various types and that on the whole there is precious little evidence of 'community' actually helping people to stay at home. Concerning the fact that 80% of elderly people at home are cared by informal care, 'community care' in the Australian context is not an alternative to 'institutional care' but the formal service provision to complement and support informal care (Graycar and Jamrozok:1993).
Development of community care services for elderly people in Australia
The origin of Australian community care services was provided by family care and private charities subsidized by governments in the early 19 th century. In 1818, the Benevolent Society was formed to give aged people ﾔindoor reliefﾕ(institutional asylum care) and ﾔoutdoor reliefﾕ (food and clothing). In 1890s, home nursing started with nursing associations for the first time. Then, in 1908, the Commonwealth Invalid and Old Age Pensions Act was established to maintain people in the community rather than being forced to enter destitute asylums. In 1940s home help started as a war-time emergency housekeeper service for young families. In 1950s Meals on Wheels began. Moreover, in 1954 the Aged Persons Homes Act stopped massive expansion of nursing home beds and pressure on the states to increase community services (Healy :1990, Sax:1993, Howe: 1990).
Although in 1969 the Gorton Liberal Government attempted to achieve a more comprehensive range of service provision for the aged at home and provided cost-shared home help and subsidies for senior citizens centres, there were some problems for the implementation of the Act. Firstly, in the late 1970s there were only 22 home helpers per 100000 compared to a ratio of 265 in Great Britain and 900 in Scandinavian countries (Healy:1990). Secondly, senior citizen centres could not become a core centre for services coordinated by the welfare officer because the officers did not have enough power to coordinate the services. In addition, elderly people tend not to label themselves as ﾔoldﾕ or as ﾔsenior citizensﾕ. The Department of Health also introduced States Grants (Paramedical) Services Act to subsidy for paramedical staff such as podiatrists and physiotherapists in 1969. In 1970 the Delivered Meals Subsidy Act, introduced by the Department of Social Services, provided subsidy to local governments and voluntary agencies (Healy:1990, Howe:1990).
The McLeay Report which was released in October, 1982 discussed the development of health and welfare services for elderly people and the evolution from the family care through care by voluntary sectors, to government involvement at Commonwealth, State and local levels. The report focused on the nature and effectiveness of those community services which already attempted to maintain elderly people in their homes, and pointed out the importance of service co-ordination to provide less fragmented, need-based care. The report recommended that all programs providing home care and accommodation for the aged be implemented under the control of one Minister, and that negotiations should be proceeded with State governments to develop more effective cost-sharing arrangements. As a mechanism to assist in such regional planning, multi-disciplinary teams should be set up, with access to the full range of services for the aged. These teams would assess the needs of elderly people and refer the people appropriately to community services or to residential care. Teams could assist in the co-ordination of service provision, contributing to the well-being of the elderly (Errey:1986).
In 1985 the Home and Community Care Act was introduced to subsume four pre-existing programs under one cost-shared arrangement with the States. The main aim of the new program was to provide a wide range of community support services so as to prevent premature or inappropriate institutionalization (Howe:1990). The 1990-91 mid-term review showed a strong support that the HACC program was effective in reducing problems of the service delivery at local level although some state governments have been reluctant to match federal increases in funding (Sax:1993).
In developed countries the population of elderly people have been growing for the past two decades because of the lowering of birth rate and lengthening of life expectancy. Australia, which has had lower average age than other developed countries, is not an exception. In fact, the population over 65 years old exceeded 12% in 1996 and is predicted to reach 13.8% in 2010. Especially those over 75 years old who comprise over one-third of the over 65s this year will comprise 47% by 2001 (Graycar and Jamrozik:1993, ABS:1996).
The co-ordination problems in the Home And Community Care program (HACC)
Firstly, many research and government enquiries on the subject of community care for elderly people in Australia point out the problems of the lack of co-ordination in the complexity of service provisions. The co-ordination of HACC for elderly people in multiple entry points potentially causes communication problems between co-ordinators/service providers and clients/carers and brings confusions particularly to elderly people. In the HACC program, the co-ordination for elderly people is implemented by different organizations such as the local doctor, Aged Care Assessment Team (ACAT), Community Options, local government, Community information services, relevant State department. According to Commonwealth Guidelines for Assessment Services,
There is a need for assessment team and service provider action to be co-ordinated
to ensure that service users receive appropriate care with minimal stress and
disruption, that services are provided in the most efficient and effective manner
and that duplication of assessment and care planning is avoided (Department of
Community Services and Health:1988,9).
However, a research study from the Centre for Applied Gerontology shows that ACAT were not necessarily involved in assessment of community care services. This result indicates that ACAT networks would have some under-recognition and under-reporting of interaction between HACC projects and ACAT (Australian Institute of Health and Welfare:1996). As for clients, the experience of being assessed would be traumatic because some elderly people are not willing to be assessed with the level of dementia or disabilities. Multiple assessment is probably inefficient because the repetition of this experience by different agencies is a complicated and confusing experience to elderly people (Fine and Graham:1992).
Also, Community Options programs began from 1987 to co-ordinate appropriate and sufficient home and community support services for frail aged people and those with disabilities. However, this program is available only for elderly people who are faced with having to enter a nursing home or hostel. If elderly people need only a little support or very intensive or specialized care, they can not apply to the programs because the funding is very limited. In addition, the service area for each office is considerably large, normally four or five local government areas. It would be impossible for a few staff to co-ordinate community care services for all individuals in each local government area (Department of Health, Housing, Local Government and Community Services:undated).
Michael Fine (1993) suggests three forms of coordination for reform. Firstly, bureaucratic coordination would be useful to coordinate the separate specialist components of the system although the model may be strongly refused by community services sectors. The second coordination is market based approach which facilitates the integration of a different range of services for each individual client. Thirdly, a local network of services such as the implementation of regular meetings with the client to discuss aspects of their individual contributions, which develop informal and formal links between the separate organizations, could be effective while maintaining the autonomy and integrity of the existing system of services.
The NSW Government is operating the Commonwealth-initiated Co-ordinated Care Trial to seek to improve the health and well being of people with complex needs through maximizing funding and service flexibility, the separation of the purchaser of services from the service provider, and the establishment of agreed and coordinated care plans. One of the proposed projects is the ﾒIntegrated Community Care Agencyﾓ, which offers a single phone number and premises that become the first point of entry for consumers to the community care system in their local areas (Sadler and Owen:1996).
Secondly, where access at multiple entry points is likely to cause the fragmentation and poor co-ordination of the service provision in community care services for elderly people. Michael Fine (1993) argues that the system at the local level is largely incapable of overcoming the structural barriers which served to isolate the individual organizations and fragment the provision of services to people at home. The potential for conflict and competition between organizations at the local level under these conditions is considerable. Coordination and cooperation between the different services is a necessary condition for the provision of a comprehensive range of assistance.
Hokenstad (1982) claims that in addition to organizational obstacles between different kinds of service providers, professional obstacles to the service linkage are evident in both the health service system and the social service system. In Australia, the co-ordination of Home and Community Care programs are hardly operated by team workers though the health service system adopts ACAT to co-ordinate services by a team including doctors, social workers, Nurse, Occupational Therapist, etc. Therefore, in community care services for elderly people, collaboration among provider disciplines among community workers can be disturbed by professional obstacles.
Michael Fine (1993) claims that each service provider should provide a more comprehensive range of assistance than is at present available to clear away the need of complicated co-ordination. It would be useful to prevent fragmentation and duplication of service by different kinds of providers and lead to a significant increase for those agencies which succeeded in providing an integrated range of assistance to clients.
Thirdly, the complexity of the funding system is likely to restrict service providers' ability to gain adequate funding for elderly people and carers. Also, there are a lot of tensions between service providers and Commonwealth/State government. These tensions come from the fact that organizations are heavily dependent on funding from State and National programs. Staff from the local community support services have expressed fears of funding cuts or imposed rationalization, resulting from their vulnerability to the decisions they can not control (Fine:1993) . Therefore, service providers found that the inflexibility of the programs by funding created difficulties for coordination and disturbed autonomy (Craswell and Patrick:1995).
Finally, the problems in the co-ordination in community care services for elderly people would have a strong relationship with a social justice strategy. The four key elements of this strategy are 1) equity in the distribution of economic resources, 2) equality of civil, legal and industrial rights, 3) fair and equal access to essential services such as housing, health and education, 4) the opportunity for participation by all in personal development, community life and decision-making (1988: Commonwealth of Australia). The different and complicated co-ordination system would bring service providers / service coordinators not only mental confusions and constraints but inequitable results reacting to consumers' complex needs Also, the co-ordination problems by bureaucratic complexity and insensitivity would prevent consumer/client groups and individual from using available services and getting appropriate information (Hokenstad:1982).
More importantly, although there has been an important change in policy process of the aged care in Australia from traditional dominance of provider groups to consumer groupsﾕ participation, elderly people are scarcely active at all in the local governments studied, and advocacy is highly fragmented (Howe:1992). In addition, it is difficult for elderly people to find an appropriate place to complain or suggest changes in their community areas. The complexity of the co-ordination system in the HACC program would prevent the promotion of direct participation in policy making by elderly people. Hokenstad (1982) states that consumer participations in the variety of self-help groups would have a potential to be an important factor in future planning for effective service networks in service delivery of community care services. He also claims that client/consumer participation at various levels of decision making in community care services could have a positive impact to service linkages and co-ordination.
The HACC program aims to achieve equitable community care services in each state. In the report of Department of Health and Community services, one of the major directions is ﾒImproving Access: Encourage an equitable allocation of resources according to the assessed needs of consumers by developing a needs-based planning model for the HACC programﾓ (1991). However, different state patterns make it difficult to achieve the national policy aim. This is because community services in the HACC are provided by complex mix of government and voluntary agencies (Healy:1990). Table.1 shows a complex diversity of service providers in each state. It is expected that there are more varied mix of providing and co-ordination systems in each local government area.
Table.1 Major providers of the basic home care services for elderly people by state:1987
Source: Shannon and Foster (1987,Table 5.1)
The history and role of local government in community care in Australia
The local government in Australia can only carry out those functions for which it is specifically authorized by legislation because it is not a sovereign sphere of government by law (Bowman and Halligan:1987). In terms of financial ability, Australian local government is the weakest among the major advanced federations, Australia, Austria, Canada, Germany, Switzerland, USA (Jones:1993). However, in relation to service delivery and planning, Australian local government has a long tradition of partnership with other spheres of government. The local government is an elected system of government, representative of its community. Therefore, the system enables the close involvement of community members in the activities and decisions of the community. Its elected character and broad responsibilities for a defined geographic area suggest that local government is, at least potentially, better placed than either Commonwealth or State governments to understand the unique features of its area and to respond to or meet local needs and conditions (Office of Local Government:1986). In addition, local government provides the only possible arena where direct democracy through public meetings, referenda, neighborhood participation systems may occur and which would influence the community care services in their community (Jones:1993). The trend has been towards increasing municipal involvements in the social service provision though in Victoria local governments have already become the major providers of social services for elderly people (Bowman and Halligan:1988). More importantly, local government would have a possibility to not only provide social services but also promote the local co-ordination of voluntary and community organizations, and manipulate a range of local resources to meet local needs and demands (Bowman:1987).
Concetta Benn (1983) argues that in social policy of the social services in Australia there has been the movement from centralism towards regionalism and localism. She also maintains that these movements would stem from two reasons. Firstly, the reduction of welfare spending would be needed by privatization, the shifting of the welfare burden from federal to state, state to local governments. Secondly, the government would like to humanize the delivery of social service by providing more close connection between consumers and service providers. However, localism does not necessarily mean the increase of service delivery and co-ordination by local government in the Australian context. This movement and strategy of ﾒlocalismﾓ has been used mainly by voluntary agencies in Australia though some local governments would use ﾒlocalismﾓ as a strategy to deliver personal social services.
As for elderly people who need a longer term community care in Australia, local governments are both actually and potentially the best basis for the local integration and co-ordination of a range of front-line community services although intensive or specialist services can be co-ordinated most effectively with a client population larger than the council area and would require planning and funding at a scale greater than the municipal. Historically in Australia the ability of local governments to plan and co-ordinate social services for elderly people at the local level has been hidden behind other spheres of government. If local government is supported financially through untied grants on a needs-related system, it could become the core point for a systematically decentralized and locally responsive and accountable service system for elderly people (Bowman:1987).
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