Aged care services – future demand and other conundrums

Judith Davey 19/5/17

 

What affects the demand for aged care services?

• Population Trends: The 85 plus age group is growing rapidly. This is where the proportion in residential care is highest and most people living in the community need some level of support. Trends in mortality rates are crucial; the lower the rate, the higher the growth in the older age groups. Migration rates are less important, certainly in the short to medium term.
• Disability trends: The incidence of disability increases with age. Assuming the prevalence of disability continues as at present, it is estimated that the number of people 85 plus with high support needs will increase by 225% between 2006 and 2036.

Estimates of population and disability trends are available and are likely to be reliable. But these are not the only factors influencing demand. Others are less predictable:

• Social change – will informal care givers be available? Paid workforce participation by the “young-old” is increasing and being encouraged. Can paid work and eldercare be compatible? Residential mobility means that potential family carers could be scattered through the country and around the world.
• Public policies on the provision and funding of care services are important and can change, along with the relative focus on institutional and home care; and the monitoring and regulation of care services. Immigration policy, which is currently being debated, will influence the availability of care workers.
• Funding of services and fiscal constraints depend on the overall economic situation, especially in a context of rising demand and rising expectations.
• Advances in health practices and technology. What changes will there be in the prevention and treatment of dementia? Tele-monitoring may allow more self-management at home. Strategies aimed at preventive initiatives and healthier ageing could reduce levels of impairment and hence the demand for care. And I have written earlier on assistive technology.
• Business and management practices can also change and will influence privatised and contracted services. These include, for example, consolidation of facilities and economies of scale, improved processes and working practice, but also whether aged care is seen as a profitable investment.

Several exercises by public, private and voluntary agencies have attempted to project the future demand for aged care services and aged care workers in New Zealand. All this work points to an increasing demand for aged care services, both at home and in institutions, and signals a likely shortfall in supply, especially in the available workforce. A Department of Labour report suggested that the number of care workers needed will rise to 48,200 in 2036. Current growth trends produce a total of 21,400, clearly not enough.

Health Workforce New Zealand estimate that from 2011 to 2026 the numbers of people receiving home support and residential care will increase by 61% and 54%, respectively. A significant shortfall in funds is predicted. Not enough money; not enough workers. This is before we even think about workforce development and training.

As well as the supply-demand conundrum, what are some of the other issues for the future?

• Finding a “client-centre” focus, giving a voice to older people’s needs and wishes.

The 2016 Health Strategy talks about “people-powered” services – enabling individuals to make choices about the care or support they receive; understanding people’s needs and preferences.  How practical is it and can we afford to take into account all the preferences of older people requiring care, assuming that subsidies will remain?

• Balance of home and institutional care –response to cost or wishes of older people?

Where should the balance be? There is a growing concern about an increasing focus on people with higher level care needs and the withdrawal of services from those receiving low-level home care. How compatible is this with a preventive approach?  The ASPIRE trials suggested more intensive home care, giving more responsibility to “unregulated” care workers. Is this realistic? Will upskilling come along with higher pay?

• Management and regulation

How do we reach an effective balance between “light touch” and heavy-handed regulation? Which will deliver better quality and better protection from abuse? Is there a trade-off between efficiency and choice?  How can innovation be promoted in a climate of claims and counter claims about funding in the sector?

• Sharing responsibility

Who should be expected to provide and fund care for dependent older people in the future and how should responsibility be shared between individuals, families, communities, the voluntary sector, private sector and government agencies? How should the costs be shared? How do we identify and build on the strengths of the different sectors in the aged care field?

Clearly complexity and pluralism is operating in the provision of care for older people. Most research demonstrates that family and formal care are more effective when they complement each other. But, responsibility must be clearly defined –how? Issues of unmet needs, poor quality, abuse, “buck passing” and gate-keeping arise where responsibility becomes contested or where shared responsibility is difficult to negotiate.  Can multi-disciplinary case conferences and planning support person-centred care, and incorporate the perspectives of carers and other family members?

A lot of questions – calling for realistic discussion if older people are to receive the care they deserve.

 

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[1] Based on notes for a workshop at the NZCCSS Conference in Wellington in 2012, led by Judith Davey.