Dr Kerryn Phelps, AMA President to the 11th Aged and Community Care Conference, Launceston

That must change…and soon.

'Change' is a word that crops up all the time when talking about aged care and what needs to be done.

Change in demography and the patterns of illness; change in the patterns of needs and of care; and a need to change the culture and attitudes towards ageing in this country.

The biggest change is getting people to focus on the human dimension of ageing and aged care.

People must realise that the work we put into aged care policy today for our parents and grandparents will set the scene for the system that awaits us when our kids are looking at options for us in our 'twilight' years.

We can't approach aged care policy in the 'third person'. It's about us, our parents, our kids, our loved ones. It's personal.

Today, one in nine Australians is 'older'; in 2020, one in four of us will be 'older'.

At present we have an aged care system that is limited by convention and stereotypes. An individual has to fit into a system, and choice is limited because supply does not meet demand - there are insufficient respite beds, waiting lists for residential aged care beds, and more aged care packages and Home and Community Care (HACC) services are needed.

There is little integration of care between hospital services, residential aged care facilities, and community services.

Change is needed if we are to keep pace with the needs of our older people. We, as decision and policy makers, have an opportunity to develop a model for seamless flexible care, if we think outside the boundaries and work together.

AMA and Aged Care

Some may think the AMA is purely a "Doctors' Union". True, but we are much more than that.

We advocate aggressively for our members on industrial matters and on health policy - but always with a parallel patient focus.

Doctors care about the health of the Australian people and the community and we work hard to ensure that there are high quality affordable health services and equity of access to those services for all Australians.

We are not afraid to speak out either on controversial issues - things like IVF, indigenous health, and the health of asylum seekers and children in detention.

The AMA has been involved with aged care issues for many years - certainly since 1962 when the AMA Federal Council first began meeting in its own right, separating from the British Medical Association.

During that year, the future of rehabilitation services and the keeping of clinical records of patients' histories in nursing homes were on the agenda.

By 1973, issues such as Government policy on admissions to nursing homes were being considered.

In 1984, the AMA responded to the Senate Select Committee on Private Hospitals and Nursing Homes, and since then the AMA has had input into Government aged care reform strategies - the mid-term review in 1990-1991, the second stage in 1993, and more recently the 1997 Aged Care Reforms.

With the introduction of the Aged Care Reforms in 1997, the Committee considered it imperative that the AMA gain a broader perspective of the issues, and so convened an Advisory Group on Care of Older People.

This group, comprising representatives from consumer organisations, provider groups, nursing associations, relevant medical colleges, and the Commonwealth Department of Health and Aged Care, meets twice a year and has proved to be an invaluable forum for understanding and questioning Government policy.

In April 2000, the AMA was one of the organisations involved in the initial meeting of what is now the National Aged Care Alliance, and has since become a sponsoring member.

The AMA values the opportunity to work with other members to develop an understanding and appreciation of the aged care sector as a whole, not just from a medical perspective. Issues associated with aged care facilities such as access, quality of care, use of restraints, and management of medications take on new meaning when seen from the perspective of consumers, providers and nursing organisations. It is in this environment of co-operation and unity that change can occur.

Changing Demography

In Australia, and many other similar countries, for the first time in human history, there are relatively large numbers of people living into their eighties and beyond.

In 1999 the population aged 85 years and over was relatively small, at 241,000, but it is projected to experience the highest growth rates of age cohorts within the population, doubling by 2021 and reaching some 1.3 million (or over 5% of the population) by 2051 Trewin, D. (2000) Population Projections, Australia, 1999 to 2101, Australian Bureau of Statistics, 2000, pps. 12-13..

There are two growth rate "peaks", with 6% growth in 2006 (associated with the post WW1 baby boom) and a higher 7% growth in 2032 (associated with the post WW11 baby boom).

Australia faces a particularly rapid increase in its aged population. Overall, the aged (65 years and over) are projected to increase by about 140% from 1997 to 2031, and the very old (80 years and over) by around 200 per cent over the same period. An ageing population means increased usage of long-term aged care services but this could possibly be offset by reduced disability rates for the aged.

There is an assumption that ageing is a process of ever-more illness and disability so that old age is to blame for the high costs of medical care. But ageing itself is not the main mechanism driving rising health-care costs.

The relationship between age, morbidity and health-care costs is not straightforward.

Demographic change is just one factor; general inflation and developments in medical technology are also contributing factors. Everyday ailments that prevail in younger populations continue into old age. Chronic diseases, which impact on life expectancy and quality of life and are characteristic of the over 75s, have already made their mark in younger years.

Changing Patterns of Illness/Ageing

The over 65 population, as a whole, consumes medical and health services at three times the rate of younger people and therefore can crowd out expenditure in other areas.

Disabling conditions which affect those aged 65 and over are related to physical conditions including arthritis, problems related to the circulatory system (particularly heart disease and stroke), and other musculoskeletal conditions. Depression can also be a disabling condition.

Another feature of illness and disability in old age is co-morbidity: the presence of more than one condition, and the effects of each condition on the others. This often

becomes particularly significant in people over eighty years.

Dementia provides a striking example of the effect of very old age on individuals.

The prevalence of dementia doubles every five years over the age of sixty, from only 0.72% (60-64) to 23.60% (84+) Jorm, AF and Korten AE (1988) A method for calculating projected increases in the number of dementia sufferers. Australian and New Zealand Journal of Psychiatry, 22, 183-189.. Whether this increase continues over the age of 85 is not clear.

Apart from dementia, there are other neurological conditions contributing to the increase in severe disability experienced by those people over eighty years of age.

Dementia and these other conditions may result in disorders of memory, cognition, behaviour, motor and sensory functions, mobility and balance. Such neurodegenerative diseases are often slowly progressive and have not yet been able to be prevented or their onset delayed as have other disorders such as heart attacks and stroke.

We can expect the systemic disorders to be overtaken by neurodegenerative diseases as the major cause of death in older people during the coming decades and also as the major cause of severe disability National Strategy for an Ageing Australia. An Older Australia, Challenges and Opportunities for all. (2001) (amended 2002) Kevin Andrews, Minister for Ageing, Commonwealth of Australia. Page 48. .

But we must also recognise that there is great diversity in the health and functional capacity of older people, and that not all old people are frail and ill. Indeed, younger old people (65 to 80) in Australia are generally able and well.

Life expectancy and disability are not uniform across population groups within Australia.

The health of populations living in rural and remote areas of Australia is worse than that of those living in capital cities and other metropolitan areas.

Indigenous Australians have higher rates of premature death from diseases of the circulatory system, cancer and external causes such as accidents, poisoning and violence, and the onset of chronic disease and ill health tends to occur earlier in these communities.

Socioeconomic disadvantage is also associated with poorer health including higher rates of premature death and increased likelihood of engaging in risk activities which contribute to ill health Ibid, page 38..

Predicting the future of illness, impairment, disability and death in the Australian community is of course difficult. It is made within our current knowledge of:

the causes of disease and its progression,

the limits of current medical technology and

the current measures of the social, economic and behavioral determinants of the health status of future generations Ibid, page 48..

One view is that, as the incidence of disease is delayed to older age, ill-health and disability will occur for a shorter period of a person's life ("compression of morbidity").

An opposite view is that, while life spans have increased, chronic illness and disability may also have increased, resulting in longer periods of life spent in ill health.

There is also a view that any gains from preventing illness or death from one type of disease are reduced or cancelled by increasing illness or death from other diseases Ibid, page 46-7.. A depressing thought!

Two particular issues that will bring about change to the health care system are:

the ageing of the "baby boomers" and

the rise in the number of very old people (80 years or more).

Baby Boomers are not afraid of change - it has followed them through their lives.

Social policy and legislative change over the past years has meant that this generation is more aware of its rights, and has higher expectations of future care, conditions and comfort.

This generation of educated health conscious consumers will demand care and accommodation in their later lives where quality and access of care and standards of living are not only available, but are met.

Changing Patterns Of Need

The vast majority of older Australians live independently and in their own homes.

Fewer than 1 in 10 people over the age of 70 live in a residential aged care facility. "Aged Care - make the choices that are right for you" Aged and Community Care Division, Department of Health and Family Services, Commonwealth of Australia 1998.

Many people are able to stay in their own home with the support of Home and Community Care (HACC) services, Community Aged Care Packages (CACPs) as well as the availability of Respite Care.

Research undertaken by the Australian Institute of Health and Welfare shows that most older people have a strong preference for remaining in their own homes wherever possible.

This has brought about an expansion of community aged care packages and has enabled people who might otherwise be eligible for low levels of residential care to receive personal care and household assistance within the community.

The number of community aged care packages providing services to people in their own homes has risen from 1,200 packages in June 1994 to over 18,000 packages in June 2000. Australian Institute of Health and Welfare Media Release "Australia's aged care 1999-2000 18 May 2001.

Older people are now only entering Residential Aged Care Facilities when support within the home is no longer adequate to meet their health care needs.

This has resulted in the residential care system now catering for an increasingly frail population with the proportion of permanent residents receiving high level care shifting from 58% at 30 June 1998 to 62% at 30 June 2000. Australian Institute of Health and Welfare Media Release "Australia's aged care 1999-2000 18 May 2001.

This also has the effect of decreasing the need for low care in facilities while increasing the need for high care beds.

We must look to designing more appropriate housing where older people can still have their independence, but also have easy access to care - perhaps 'cluster' housing, close to shops and health care facilities, and with a resident carer.

Last year I called for more double beds in Residential Aged Care Facilities.

When thinking of more appropriate housing and accommodation we must remember that just because people are ageing, it doesn't mean that they lose the ability to give and receive love.

At this time of their lives they need, more than ever, the love and support of other human beings. Age shall not weary them.

Sometimes it may not be appropriate, but wherever possible we need to have appropriate accommodation so that partners can stay together rather than be in separate facilities, often some distance apart.

Linked to the wish by older people to stay in their own homes, is the need for seamless and flexible care. This means that older people should be able to receive an appropriate level of care when they need it.

If an older person has need for acute care in hospital, they should then have access to sub-acute care before either returning to the community or entering a Residential Aged Care Facility. A care 'gap' is widening between hospital and residential settings that few countries are addressing.

The AMA has been talking to all who will listen - the profession, Government, aged care providers, consumers, other health care providers - and saying that there is a need for transitional care.

That is a facility where sub-acute care can be provided. This would cater for older people who do not need acute care in hospital, but need further recovery time before returning to their home or to a Residential Aged Care Facility. It would provide more appropriate care, accommodation and therapy than patients are receiving at present in hospital - and free up hospital beds for those patients who need acute care.

There are hurdles - State/Federal funding complications, a need for a higher nurse to patient ratio than in Aged Care Facilities, more integrated medical services which would include GPs and specialists, and a defined and experienced multidisciplinary care team - but the hurdles are not insurmountable.

With a more seamless health and aged care system, people could move from hospital to transitional care then either back to their homes to be supported by community care or move into high or low facility care with funding following the patient seamlessly wherever they are.

Ageing Australians are an integral part of the community and a significant segment of the health care system. They need appropriate care just as much as any other Australian. Why should it be considered acceptable for elderly people to wait in hospital for up to three months when the accommodation and care is inappropriate?

Some trials for transitional care are now in place. The AMA awaits the evaluation of these trials with great interest, and hopes that from them there can be a nationally accepted model integrated into the health care system.

While talking about appropriate care, I cannot let this opportunity go by without mentioning the 6,046 people under the age of 65 living in residential aged care facilities throughout Australia due to lack of alternative accommodation for young people with a disabilities.

There is an urgent need for alternative accommodation models to be developed for these young people with a focus on rehabilitation and quality of life. They should have access to accommodation options that not only meet their high support needs but also provide for social and personal development.

Consideration could be given to reallocating bed licences, so that some residential facilities are specifically allocated for the young people. This means that younger people who at present occupy beds in nursing homes with older people can be relocated to a facility that is occupied by younger people and where the focus is on their care and developmental needs.

There must be commitment from both Commonwealth and State Governments to work together to ensure younger people with disabilities live in appropriate and adequately funded accommodation.

The AMA joins with aged and disability services in calling for appropriately funded alternative accommodation options for younger people with disabilities.

Changing Patterns Of Care

If older people wish to stay in their homes longer, then the health system will have to move away from supporting episodic care to supporting continuity of care. Individual approaches to treatment will require a team approach that will be underpinned by evidence and outcomes, clinical pathways and guidelines.

Teams will need to comprise medical practitioners and health care professionals across the sector - GPs, specialists, community nurses, allied health care professionals, pharmacists and representatives from community agencies.

The use of the team approach will direct appropriate care where it is needed, and make for smooth transition from acute to sub-acute care and from community to facility care.

Communication structures would need to be in place, such as a patient-accessible electronic home care record system which would allow instant contact with a range of healthcare professionals, information sources and other health services in an electronic distributed environment. Ibid.

Multidisciplinary teams and more integrated approaches to providing medical and health services have been introduced with the Co-ordinated Care Trials and Enhanced Primary Care programs.

These programs have been designed to assist people with chronic illnesses and complex care needs, and include care planning, case conferencing and health assessments.

To achieve innovative changes to the health system, we will need to train an increased number of medical practitioners who work in specialties associated with ageing and ageing illnesses.

There will need to be changes in medical practice. Doctors will need to move out of their surgeries to treat more people in their own homes and Residential Aged Care Facilities so that care is provided where it will be needed.

There was a time when most GPs did home visits as part of their daily routine.

Many GPs have now had to sacrifice this practice because it is not a viable option both in terms of time and remuneration. However, the barriers against home visits are tripled when we discuss GPs attending patients in Residential Aged Care Facilities.

The number of residents in Aged Care Facilities in 1998 was 129,403 and the number of attendances by GPs to the facilities was 1,557,570. In 2000, the number of residents increased to 130,316 while the number of attendances by GPs to the facilities dropped to 1,519,301.

This is disconcerting when other data show that dependency levels continue to rise among both high and low level residents.

So why are there fewer GPs visiting Residential Aged Care Facilities?

Most providers encourage the residents to retain their GP when they enter a facility and continuity of care with their patients is an important aspect in patient care for a GP - it means that they know the patient's medical history and their psycho-social background, and the GP is part of the patient's support network.

Herein lies the first barrier - the amount of time spent in travelling. Because of the shortage of Residential Aged Care Facility beds, patients rarely have the luxury of choosing the location of the facility where they are going to live.

Also, the relocation of some Residential Aged Care Facilities from inner suburban sites to the outer urban fringe means that patients have little choice but to move with the facilities away from their family, friends and GP.

Either a GP closer to the facility, who has no history of the patients, takes over the care, or the original GP spends periods of unpaid time travelling.

When the GP arrives at a Residential Aged Care Facility there are still further barriers.

The GP must wait for nursing staff before it is possible to see a patient. To be able to provide high quality care, in fact any care, doctors must work in collaboration with the nursing staff.

The medical profession is sympathetic to the nursing profession's difficulties with aged care facilities, and supports its call for wage parity and more realistic workloads.

Until this happens, the GPs' role working within a facility is considerably hampered and high clinical standards of care harder to achieve for residents/patients.

There is often a lack of appropriate examination facilities such as a room set aside to see patients, and basic equipment such as bright lights needed for viewing wounds.

And that is only the beginning …there is considerable unremunerated time which can be spent in the doctor's private time when not with the patient, on issues such as writing scripts, checking medication records and dosages, arranging urgent pathology tests, hospitalisation, ambulances, interviewing relatives.

The problem of delivery of medical care to residents/patients of Aged Care Facilities is still part of the wider problem of delivery of medical care to an ageing population.

Accreditation should encourage quality improvement and best practice in medical and health care.

Medicare items have yet to reflect both the clinical and non-face-to-face work needs of Medical Practitioners visiting Residential Aged Care Facilities.

Until a more equitable formula for the fee-for-service attendances has been devised, and a more appropriate environment in which to work within a facility has been developed, there will continue to be an exodus of doctors from working within Residential Aged Care Facilities.

To address the challenging area of aged care, we must think outside the traditional boundaries to seek innovative ways to address the health care needs of the ageing population in the coming years.

The problem needs to be addressed now - not in five or ten years' time. Then it will be too late.

Funding

An ever-present problem is the funding arrangements of health care, which cross both State and Commonwealth jurisdictions. Until the negative implications of cost shifting changes to a more positive cooperative arrangement, the reality of seamless care will be out of reach.

With the demographic changes and a much-needed revision of health care provision, it is unlikely that aged care will be able to continue with its present financial arrangements and funding mechanisms.

Several methods of funding have been suggested in recent years - such as Pay-As-You-Go (PAYG) where current costs are paid from current revenue), Forward funding (private insurance schemes) or Mixed Funding Models Webster J. Financing Long-Term Aged Care. A discussion paper prepared for the National Aged Care Alliance. 2001.p2 - and the debate continues in regards to appropriate models.

Whichever model is decided upon, the issue of the changing demographics and the need for appropriate health care delivery must be addressed.

We need to contribute to the broader health financing debate such as the agenda for change in the next five years which we hope will be fixed by the Australian Health Care Agreements.

This situation will become more critical as we approach 2010 and the cost pressures escalate significantly.

Conclusion

It is time now to consider change within the health care system for older people, and it is up to the aged care sector to lead debate and action.

Benchmarking of accessible and appropriate quality care must be the objective. To achieve this objective will take cultural innovative change.

The medical profession must be part of a team providing seamless care which bridges the current gaps, sometimes chasms, between preventive and health maintenance services, family and other carer services, services based in medical practice rooms and surgeries, hospital services, home based services, and residential aged care services.

To achieve this, we need to develop and be open to different ways of working and communicating, while remaining vigilant that ethical and care standards are maintained.

In view of the increasing demands on an already overburdened system, the total needs of the older population must still be properly addressed.

Access to a high standard of clinical care is a right and must never be denied on the basis of age, disability or perceived societal usefulness.

The AMA is continuing to work with other members of the aged care sector and with Government in order to achieve a flexible integrated health care system which allows choice of health care delivery to meet individual care needs.

But, above all, let's get some humanity and compassion back into the debate. We are dealing with the quality of life of fellow human beings - family, friends, relatives, the people who forged our community, our way of life.

Let's remove fear from the ageing process. After all, it'll be us one day.

Thank you.