THE McLEAY REPORT Cutting the $1000m Cake

J. M. HEMER

Preface: The Federal Government’s annual contribution to

accommodation and home care programs for the aged can be expected to pass the $1,000m mark in the next Budget. And while the expenditure on these programs climbs significantly there are increasing criticisms of the present arrangements. Many of the aged who require basic home care services to enable them to live in the community (meals on wheels, home help, even district nursing) are unable to receive these services and a not inconsiderable number of the aged find themselves unwilling patients within nursing homes - where the costs to the individual and the community can be very considerable. The aged, their families, community agencies and institutions caring for the aged, politicians and taxpayers are increasingly questioning the inadequacies, expense and mismatch of services which are Australia’s present arrangements for aged care.

It was against this background that the House of Representatives Standing Committee on Expenditure undertook a major inquiry into accommodation and home care for the aged. Their Report*, recently released, is reviewed in this Working Paper.

The Report can be expected to presage significant changes in the Federal Government’s role in and funding of aged care. Informed public debate on the Report and on aged care generally is important to ensure that any and all changes are for the well-being of Australia’s increasingly aged population. The purpose of this Working Paper is to aid this public discussion.

Introduction: On the 28th October 1982 a report of the House of

Representatives Standing Committee on Expenditure was tabled in Parliament. This Report, entitled:

‘IN A HOME OR A T HOME: accommodation and home care for the aged’

is the latest in a long line of reports prepared for the Commonwealth Government on the care of the aged (1). It is the culmination of two years work by a backbench subcommittee consisting of representatives from the three major political parties. The sub- committee was ably assisted by two expert advisers: Dr Bruce Ford (2) and Ms Anna Howe (3) and had the services of a full-time Secretariat.

It is generally the case that subcommittees are only established and reports are only commissioned after there is an evident problem. And so it was with this subcommittee. There had been growing concerns about many aspects of the Federal Government’s programs for aged care including:

the increasing number, and percentage, of the aged in the population; ’ the availability and quality of many aged care services; . the rapidly escalating costs of nursing home care;

the fragmentation of responsibility between Federal and State governments.

These political and governmental concerns were also In a Home or At Home: accommodation and home care for the nged. Report from the House of Representatives Standing Committee on Expenditure, October 1982. Locally known as the McLeay Report after Mr L. B. McLeay MP, Chairman of the Subcommittee.

mirrored in dissatisfaction at the community level - by the aged themselves, by their families. and by providers of services. The need for change was evident two years ago when the inquiry was instigated. But for the last two years there has been a tendency by government (at the political, policy development and administrative levels) to make no significant changes pending this Report. SO by now the requirement for action on the complex maze of Federal arrangements for care and accommodation of the aged is even more pressing.

The Report is certainly no anticlimax. I t is a significant document which identifies the major problems confronting the aged and those who care for them, discusses the development and the strengths and weaknesses of the present arrangements and provides clear recommendations aimed at improving the social and cost effectiveness of this major industry. Few, i f any aspects of aged care escape a thorough going and often hard hitting review in this document. And whatever one’s interest in ageing, this Report is priority reading, particularly as government will have no option but to make some significant changes in the immediate future. Care of the aged is now a significant community and political concern. This Report is a major catalyst spurring on action, and as this is a Parliamentary Report, government must respond to its findings and recommendations within six months.

The Committee’s Approach: To understand the complex and inter-related fields

of accommodation and home care, the Committee visfted all States, received over 220 submissions, heard from more than 125 witnesses and visited a range of facilities providing for the aged. It received input from all parts of the spectrum of aged care including the aged consumers of these services, with the notable exception of general practitioners or their representative bodies. The comprehensiveness of this background work is mirrored in the Report which runs to I 1 1 pages plus various appendices. The Report is well structured. I t explains the historical development of programs as we now know them, draws out the current dilemmas and puts forward a significant series of recommendations for future development. This Report, as opposed to some government publications, is quite ‘readable’; with the first one or two paragraphs of each chapter giving an outline of the contents to follow, with adequate subheadings, and with bold type emphasizing significant issues and recommendations. Quotes from witnesses or submissions effectively highlight the text.

However, the content ensures this is not fast or easy reading. There is a wealth of major issues to be addressed in any wide ranging report on aged care and this document does not baulk at the task. It is solid reading with the many issues being extensively and competently analysed.

The Committee was concerned to ensure that the Report was practical and stood a good chance of being accepted. They were only too conscious of the lack of action o n the many earlier Aged Reports (4). They included specific recommendations to enhance the chances of this Report being implemented.

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Prior to completing its work the Committee also took the novel and bold step of circulating its Preliminary Conclusions on a confidential basis to a number of key people. I t is understood this is the first time that a Parliamentary Committee has done this and i t underlines the positive approach the Committee took to its task. The responses received helped to further refine the approaches now recommended. TO further ensure the Report was ‘implementable’ the Committee stresses an overall strategy and time frame. I t identifies those issues which should be put in order in the short term and then lists a series of mid to long term steps which would build on these earlier actions. A body specifically charged with monitoring the implementation of the Report is recommended as is a further Report to Parliament within 5 years. This would describe government’s achievements to that date and its further plans. Furthermore, the Chairman of the Expenditure Committee, Mr S. A. Lusher MP, and the Chairman of this Subcommittee, Mr L. B. McLeay MP, have already visited several States to encourage acceptance of the Report.

The Committee has thus made valiant attempts to ensure that this Report does not suffer the apparent fate of earlier aged care reports. Only time will tell i f they were successful.

Main Thrusts of the Report: The Report develops several major themes:

the predominance of institutional care over domiciliary care:

action needed to redress this balance; accommodation for the needy aged; policy and program ‘drift’.

and constructs a major package of recommendations to tackle these issues.

The 47 major recommendations are divided into two categories. Firstly, those recommendations for attention in the short term. Here the Committee is (probably r ight ly) assuming that financial arrangements and functional responsibilities between the Commonwealth and the States will not alter in the near future. They therefore look first to a rationalization and improvement of present programs within the existing FederalIState arrangements. In the second category of recommendations the Committee aims to enable a major transfer of responsibility for aged care to the States in the medium to long term.

Within the first grouping the Report makes three major recommendations that would change the face of Federal ageing programs. The present hotchpotch (5) of separately administered, differently funded and unco-ordinated programs would be brought together into two main streams. One providing for all extended care in the community and the other for all nursing home arrangements. One Commonwealth Minister, the Minister for Health, would be responsible (accountable?) for both of these programs thus facilitating better integration of the Federal Government’s involvement with aged care. Funding for accommodation for the aged would be re-routed to ensure assistance was provided to those most in need.

The Committee focused their second category of recommendations on a medium to longer term strategy - for attention over a period of five years. During this time the administration of the newly reconstituted aged care programs - the Extended Care Program and the Nursing Home Care Program - would be

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completely transferred to the States with a consequential rearrangement of funding.

This Working Paper will now consider the Report and its implications in some detail.

Institutional and Domiciliary Care: A major emphasis is on the preponderance of

institutional care over domiciliary care and the need to redress this balance.

This concern is not surprising when i t is recalled that the Federal Government will spend some 5800m on residential care this year and approximately S77m on all forms of domiciliary services. I t is worth noting here that the vast majority (ninety-three percent) of aged people in Australia live in normal households in the community with some five to seven percent in institutions such as nursing homes and aged persons hostels. Only five percent receive any form(s) of domiciliary service. The Report points out that a number of studies show that about one-quarter of the aged presently in nursing homes could be cared for in the community i f adequate domiciliary care services were available ( 6 ) .

The reasons for this predominance of institutional care are competently analysed and include the following issues:

The Nursing Home Program is shown to be outside of the normal Budget consideration (and control) of Cabinet. Expenditure on this program is determined by the number of approved beds and the rate of payment per bed - neither of which are decided by Cabinet. However in respect of Domiciliary Care programs Cabinet individually determines the funding allocation in each Budget, and can quite explicitly ration these services.

Considerable disincentives and anomalies within the present arrangements encourage the growth in nursing home expenditure while inhibiting expansion of domiciliary care. The most telling of these (and the most expensive in both human and economic terms) are those relating to funding arrangements for the differing programs. Presently the Corn- monwealth Government picks up the tab. for virtually all residential care whereas the domiciliary care programs are generally cost shared with the States. The States, not unnaturally, hesitate to put their funds into domiciliary programs which could provide an alternative to expensive nursing home care for many aged. Nor do the States have any incentive to inhibit the growth of the alternative high cost nursing home care as the Commonwealth is funding this. The aged (and the total taxpaying community) are the continual losers under these arrangements.

Present arrangements allow 50 nursing home beds for every lo00 persons aged 65 and over, but this ratio has ‘no basis as an estimation of need - i t is merely the average of provision that existed in 1972’ (p.57). Although this is only a guideline, with no quantitative basis, it has now become the measure against which these very expensive facilities are demanded and provided. On the other hand, there are no accepted level of provision guidelines for domiciliary services and so agencies have no

leverage to request funding for them. The Budget allocation remains the determinant.

The Committee identified an apparent increasing expectation of admission to a nursing home as normal progression for many aged. The aged (or their relatives) put their name down on already inflated waiting lists as a form of insurance. However few of the aged ever move to a nursing home; obviously the numbers increase with age but even in the age bracket 80-84 years 106.000 aged were living in private dwellings compared with only 24,000 in hospitals, mental hospitals, nursing homes and homes for the aged (Table 4.4, p.34). As a nation we go on spending very considerable amounts on institutional care for a small minority whilst severely restricting funding to better maintain the much larger number of aged in the community.

Domiciliary programs were found to be par t icu lar ly underdeveloped. This is understandable given the limited funding made available; but the situation is further worsened by several other factors. The community care providers lack cohesion (as they provide a series of quite separate programs) and they do not have the well integrated and formalized government procedures which apply to the nursing home industry. The programs are funded from two separate Commonwealth Departments (Health and Social Security) and often are only available if matching funding is provided by State or local government.

The Committee also pointed out that provision of funding under most present aged programs relies on the basis of submissions being received from interested organizations. Government funding goes to those who ask for i t and only recently has the question of directing services into areas of greatest need been really tackled. Thus the spread of present accommodation, Senior Citizens Centres and domiciliary services is far from equitable.

To address these problems the Committee suggests major changes aimed at containing nursing home expenditure whilst increasing home care provisions. Two major new programs, the Extended Care Program and the Nursing Home Care Program, are recommended. These would integrate and expand on present arrangements; the one being responsible for a wide range of programs aimed at supporting aged in the community, the other a t all nursing home provis- ions.

Extended Care Program: The new Extended Care Program would involve:

subsuming the present funding for home care, paramedical, home nursing and delivered meals;

a new Attendant Care Allowance replacing the Domiciliary Nursing Care Benefit and the Personal Care Subsidy;

cessation of the matching funding conditions;

the funding and development as assessment teams.

Additional domiciliary services are envisaged (including home maintenance and transport) and

greater flexibility is suggested in the present services. The requirement for matching funding from State (or local) government would be dropped thus removing one significant disincentive to expanded domiciliary care and putting i t on a more equal footing with institutional care.

The present State Grants Acts require that services be provided ‘in the home’ - this requirement would be removed allowing wider ranging services such as transport and day care ‘in order to maintain a person in the home’. Likewise, the present Home Nursing arrangements would be broadened to allow for the employment of Home Health Aides (A recent study had shown the practical benefits to be gained from such a move) (7).

These provisions, if appropriately funded and actively taken up, would make major improvements possible in the well-being of many of the frail aged living in the community.

Domiciliary Care is presently of widely divergent standards and availability across the nation. I t will take some time, even i f considerable funding is made available, for a reasonable spread, quality and range of domiciliary care to become available; and planning will need to take this into account. In fact some imaginative and innovative arrangements will be necessary to ensure an effective, equitable and rapid development of domiciliary care. Government should immediately consider how this is to be best achieved: the ‘machinery’ as much as the funding will be important here.

The Attendant Care concept was actively promoted by and for the handicapped during the International Year of Disabled Persons. The Commonwealth Government has appeared less than enthusiastic about new expenditure of the potential order of such a scheme for the handicapped of ‘working age’, let alone for what is a considerably expanded number i f apclied to the aged also.

A recent announcement by the Minister for Social Security indicated a $100,000 pilot program for Attendant Care for the handicapped of working age. I t is unlikely government would proceed to implement any further Attendant Care program before this pilot had been fully evaluated (and cost implications were determined). Furthermore, determination of eligibility for Attendant Care is a prime role for assessment teams and until assessment teams are on the ground i t would be difficult to implement. These factors which may delay (or even abort) the Attendant Care component should not be used to block the development of the remainder of the Extended Care Program. Furthermore i t should be borne in mind that the committee has taken two presently available government benefits, the Domiciliary Nursing Care Benefit and the Personal Care Subsidy as the basis for this proposal. Eligibility conditions and funding for these are already available which makes the extension here proposed quite reasonable.

I f the Extended Care Program is to be regarded as ‘an alternative’ to nursing home care (10.16) it will need to provide 7 day/week and 24 hour/day coverage for some aged persons and the range of services will need to extend well beyond the few traditional models we presently have. If this is to be provided by paid staff the monetary cost in intensive cases will approach (and possibly exceed) nursing home costs for that patient. It could readily exceed the cost of present hostel accommodation. I f the intensive and extensive

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cover is to be provided essentially by families with some backup from salaried services, the personal and physical demands on the ‘carers’ are such that only some can cope for any lengthy period. The provision of Attendant Care Allowance and Respite Care as recommended would lighten the otherwise intense demands of the ‘carer’ role (8).

Two other points are worth noting: firstly many ag- ed persons who would otherwise be in nursing homes are presently cared for a t home, sometimes with few or no other services; and secondly (and too easily forgot- ten) dollar costs are not the only consideration in care of the aged.

Nursing Home Care Program: To achieve more socially appropriate and cost

effective nursing home arrangements the Committee proposes a new Nursing Home Care Program. This would give fuller recognition to the close links that already exist between nursing homes and State hospital systems, and provide much more control on nursing home growth, funding and admissions.

The suggested Program constitutes a major departure from the present arrangements. Financial arrangements would be restructured and a uniform standard for funding would apply between all States and between all types of nursing homes. Grants would be made from the Commonwealth to the States, which would be able to ‘contract out to providers of services’. Allocations to each State would eventually be based on the number of aged in the State and it is anticipated that there would be a much better alignment of hospital systems and the nursing home sector.

Controls would be placed on the expansion of nursing home numbers including a withdrawal by the Commonwealth from any further capital funding for nursing homes and no recurrent payments for beds not already approved. In all instances of requests for new beds the alternative option of community care would need to be explored, any new beds would be limited to areas of demonstrated scarcity and the decision- making on extra beds or increased benefits would be reserved for Ministers when framing the overall Budget.

The importance of respite beds to support those caring for the aged at home is strongly supported and such provision is recommended.

A significant recommendation relates to the ownership of nursing homes. There have been criticisms that doctors as owners of nursing homes refer to them their own patients and are thus able to ensure high profitability by keeping occupancy high and admitting patients with low care needs. (A Senate Committee is also investigating both private hospitals and nursing homes in this regard) (9). The (McLeay) Report recommends that the names, addresses and occupations of all substantial owners of non- government nursing homes be made publicly available and be provided to each potential patient. Such a recommendation appears eminently reasonable and necessary, if both aged persons and taxpayers are to be safeguarded.

The uniform standard of funding is seen by some as a major issue: in the short term the Committee recommends (Recommendation 4.3) that the Commonwealth fund a uniform standard of nursing hours per patient - moving over time to the provision of grants to the States based on the number of aged

persons in each State (Recommendation 4.2). This latter basis does ‘not imply that the States should actually provide uniform levels of nursing home care - either in terms of bed to population ratios or nursing hours’ (paragraph 6.30). The States will be able to set their own priorities and make their own ‘trade offs’ under this later arrangement, although the recommendation for the short term could be more problematic for nursing homes in some States.

The Committee is less than clear on its recommendations relating to increases in the number of nursing home beds. Certainly a number of recommendations aim to contain nursing home expenditure. Some suggest no new nursing homes (Recommendations 4.2.4. paragraph 6.3 1) but a further group of recommendations accept that some increase is inevitable (Recommendations 4.10,4.12) - even in the short term and obviously in the longer term. Certainly the allocation of funds to the States which will then have to determine priorities will be a restraining influence on increases. The Committee may be merely accepting political reality and adapting a pragmatic strategy - trying to stop further nursing beds but accepting that if this is impractical then at least having a well developed ‘fall back’ position whereby alternative domiciliary care is considered, where inappropriate bed ratios are not used as the yardstick and where a t least any new beds are focused into areas of need. If this is a rationally developed ‘political’ stance of the Committee it makes good sense.

The Report does not initially appear to come to grips with the major question of the interchangeability between nursing home care and domiciliary care. A number of researchers have tackled this but i t remains a key question (11). Certainly Australia has an apparently heavy reliance on nursing home accommodation and an underdeveloped domiciliary service system in comparison with some other countries. (Underdeveloped both in terms of forms of services, and geographic spread of services.) Perhaps the strength of the Report (and its main thesis) is that there is no ‘automatic’ or ‘notional’ interchange - it is determined by what is provided, and by providing certain options a substitution effect can be achieved.

Assessment: Adequate assessment is seen as essential and

perhaps the pivotal component of any total package of aged care services. The ‘primary aim of assessment is to match services to the level of care which is most appropriate to the patient’s degree of dependency and to ensure in particular that patients entering facilities catering for high levels of dependency need the level of care provided’ (p.94). Commonwealth funding to enable the establishment of assessment teams is recommended (Recommendations 3.10,3.11).

These teams would consider all applications for all nursing homes. This is a major shift from present arrangements whereby (subject to bed availability virtually all referred patients are accepted and where eligibility criteria vary considerably between individual doctors and individual nursing homes. The teams were general ly envisaged as being multidisciplinary, based in hospitals and active in the co-ordination of services a t the regional level.

A recent Victorian Report goes one stage further by pointing out that assessment must be part of the ongoing treating and caring process and that no staff

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should be solely involved in assessment (10). This aims to ensure that realistic assessments are made and that services remain responsive.

The Committee rightly accepts that a range of alternative services must be available if assessment is to be effective. Too often the lack of alternatives commits aged persons prematurely to overly dependent levels of care. This emphasizes the necessity for the development of extended community care to, proceed simultaneously with the development of assessment teams.

A significant role of assessment teams is in identifying and articulating needs in the community and developing the appropriate services to meet these. With their ‘hands-on’ practical experience in their own local area,they can be expected to be the catalysts for necessary improvements.

The Committee did address what is a major question in providing additional domiciliary care for the aged - that of eligibility for services. Naturally enough, i f a wide range of ‘free’ services are readily available to support the aged living in the community, some of those who are presently coping independently may well seek these newly available services. This demand needs to be contained and yet it is to government’s advantage to make domiciliary care an attractive and accessible alternative to the usually more expensive institutional care. The establishment of assessment teams is recommended to ensure that appropriate care is provided to those who need it. They would also seek to ensure that no greater care than is necessary would be provided, thus limiting the very high (financial, human and dependency) costs of inappropriate admission and care.

The Committee has not clarified the extent of the role of assessment - d o they have a role in assessing patients for the relatively low level forms of care such as Meals on Wheels? I f they need to extend into these areas as well as assessing all applicants for Nursing Home Care and for Attendant Care, then the Report’s estimation of the resources required might be too conservative. I t is also argued that a catchment area of 250,000 population may be too large for the team to really remain in touch with local services. These are however practical details which can be further considered. The important point remains that good assessment is the key to appropriate care and that effective assessment teams will be a powerful force in developing local and appropriate services

Accommodation Issues: The Committee drew the necessary distinction

‘between accommodation assistance for the low income aged who are otherwise independent, and provision of care to the frail aged at all income levels and in all types of housing’ (p.48). The provision of domiciliary care rests on the prerequisite that the aged are appropriately housed. Furthermore, without appropriate and affordable accommodation, the poor aged can be shunted into higher levels of care than they need merely t o provide them with accommodation.

Accommodation is thus a crucial issue especially for the poor aged. Present arrangements, particularly those of the Aged or Disabled Persons Homes Act, were found t o be far from satisfactory. The ‘scheme has become a government rehousing program for the well-off rather than a low cost accommodation scheme for those . . . in need’ (p.40). This is a good example of the program ‘drift’ that the Committee variously

identified - wherein the original intentions of Parliament and of a program have considerably moved over time - bearing in mind some of these programs are almost thirty years old.

As the organizations benefiting under this Act often provide the spectrum of accommodation services, from units through hostels to nursing homes, the committee identified a strong tendency for aged persons to enter these accommodation forms well before they need such care, merely to ensure their access to a nursing home should they later need it. This has the further adverse effect of virtually excluding admissions of individuals from outside the organization’s sphere of influence - a ‘closed shop’ approach. The Report argues that provision of nursing home care (and home care services) should be available equally to aged people wherever they may be - that present residence should not determine eligibility.

The Committee reiterated the often expressed government policy that assistance should be directed to those most in need - that the very expensive accommodation assistance provided should be better targeted. To achieve this i t recommended that no more approvals be granted under the Aged or Disabled Persons Homes Act and that all future capital assistance for accommodation be provided under the FederalIState Housing Agreement. This Agreement focuses housing assistance on those in financial need. It has recently been rewritten and enables a variety of flexible arrangements - i t could be used to fund the present models of aged accommodation and also to develop newer approaches to better meet aged persons’ accommodation needs for instance, the Committee recognised that low cost inner city boarding houses have traditionally met the accommodation needs of many aged, but that as these buildings or their sites are being redeveloped or converted, many of the aged are dislocated - even resulting in inappropriate admission to nursing homes. The new Housing Agreement could be used to purchase, construct or even manage boarding houses to ensure this important alternative accommodation form for aged.

The difficulties confronting the aged pensioner who is required to pay private rents are well documented. Even i f they could obtain a one-bedroom flat in the cheapest 20% of the market they would pay out 48% of their entire pension and supplementary (rental) assistance on rent (12). (These figures are based on the average of all capital cities in August 1980: rents in some cities are notoriously more expensive.) Aged private tenants are at high risk of poverty.

Pensioners who own or are buying their own home, or who are public tenants, have received, or are receiving, considerable public assistance (home purchase assistance schemes including low interest mortgages, local government rate rebates, public rental subsidies). To ensure appropriate public assistance to private tenants, the Committee recommended that Supplementary Assistance (presently a maximum of ten dollars per week) could be varied in line with rental costs. This would greatly assist the many aged now having very little cash left after paying rent.

The needs of the aged home owner/purchaser were addressed by the recommendation that home maintenance and repair services should be available under the Extended Care Program. Services of this type are already operating in a minor way in several

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localities and enhance the ability of aged people to remain in their own homes.

The recommendation that no new approvals be granted under the Aged or Disabled Persons Homes Act is certain to bring forth concerted opposition. Many large and influential charitable and religious organizations are major beneficiaries under present arrangements. They have accumulated very considerable real estate and accommodation stock - over which the Commonwealth, despite its original substantial funding, now has virtually no control. Furthermore, the ongoing patient costs for much of this accommodation are heavily subsidized by the government even though the organisation’s admission poIicy may mean that the accommodation is less than appropriately utilized.

Government thus finds itself giving substantial funding to very expensive and sometimes poorly targeted aged accommodation. I f its frequent policy pronouncements, that government assistance should be cost efficient and directed to those most in need, is to mean anything, it is apparent that some major changes are necessary. However, it is by no means clear that government will be prepared to withstand the concerted pressure from organizations that benefit under the present system.

Transfer to the States: The Report envisages that once these new Programs

(Extended Care and Nursing Home Care) are established the responsibility for their administration should be transferred from the Commonwealth Government to the States.

Administrative responsibility however, is one thing; financial responsibility is an equally important consideration, particularly for the States i f they were 10 take on this major new role. The Committee recommends significant bilateral discussions to develop a five year Agreement covering the level of grants to be made available. After that transition stage all payments would be absorbed into the Tax Sharing Arrangements.

The aim is that the States would ensure a closer arrangement between these aged care programs and their present health, welfare and housing services. The States are also better positioned to allocate aged programs on a regional basis and to attune them to local needs while ensuring they are well linked with local government services.

Such a transfer of responsibility raises the basic question of the Commonwealth role in the provision of services. Should (or even can) the Commonwealth ensure a basic level of services uniformly available across the whole nation, or are considerably variations between the States to be the norm? This question has been unresolved since Federation with strong arguments advanced for both models. It will not be resolved in the near future; political ideology and political expediency will remain the determinants. To that extent the Committee is realistic and in line with the times. The proposals sit reasonably with the present government’s ‘New Federalism’ and with regional developments occurring in most State administrations. They certainly should make services responsive to local needs and would overcome the present divided responsibilities between Federal and State governments. These divided responsibilities create major problems at present.

Two points of criticism of the Report are made at this stage. Firstly, the Committee’s emphasis on the

role of local government may be unduly influenced by the recent work of the Advisory Council for Inter- Government Relations or the Victorian experience of their two Advisers. That State has a better developed local government role in social welfare and aged care than any other State or Territory. It is not at all clear- cut that local government in other States (and even in some areas of Victoria) would yet be as appropriate. In the longer term and with appropriate encouragement local government could be a very appropriate structure for the provision of a wide range of ‘human’ services.

And secondly, the recommendations 5.2 and 5.3, relating to planning and delivery of services by State and local governments and a t a regional level, appear to falter in really pinning down responsibility between State and local government. This needs to be clearly resolved to minimize buck passing and divided lines of control (13), as presently occurs between Federal and State governments.

Policy Drift: Another significant theme of the Report related to

policy and program ‘drift’. The Committee found that programs ‘on the ground’ often appeared very different from Minister’s expressed policy statement or from Parliament’s initial intent. For example, the original philosophy of the government’s programs of accommodation for the needy aged has been somewhat bypassed by present practices including access by ‘donation’. The Report also sketches the incremental but significant changes that have resulted from departmental administrative decisions. A further ’drift’ occurs between the Commonwealth intentions and the programs implemented at the State government, local government or voluntary organization level. The growth and profitability of the private nursing home sector is another example - presumably the government of the day did not intentionally set out to establish the system we now know. The Report does not discuss the intra-program drift wherein the same program as delivered in one area may be quite different from that available to residents in another or even adjoining locality.

Much of this movement is positive and realistic - keeping programs more attuned to current developments or localized differences. I t is also quite understandable considering the time these programs have been in operation. But it does point up that some purposeful decisions are needed after these years of ‘drift’.

The Committee accepts that policy and programs should not stand still. but felt that as such significant shifts had occureed it was appropriate that Parliament should re-examine and re-endorse substantial new emphases in aged care. This Report should be seen as a key part of that process.

Senior Citizens Centres: Senior Citizens Centres were found to have not

generally fulfilled the original intentions held for them, namely that they should become ‘a base for health and welfare services for the aged as well as social and recreational centres’ (14). Some were found to be exclusive in membership and often did not extend beyond a social and recreational role. The Committee doubts that they presently constitute a cost-effective form of assistance to the aged. Rather they suggest these or similar Centres should become a

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base for the development of community services. Certainly Senior Citizens Centres are a ready-made base for much more dynamic community services aiding the less than fit elderly. But such a change may be difficult to introduce in those clubs which now have exclusive membership. ‘clique control’ and ‘bowls and bingo’ programs.

Where Senior Citizens Centres do not move to take up these broader community service functions i t will be crucial that some other agency steps into the breach. In all localities some one centre needs to accept responsibility for the co-ordination of present services and for the development of further programs to fill identified gaps. It may be that regionalized State services and/or local government services are the prime base for much of this essential role.

Aged Care Tribunal: Recent criticism has been levelled at the quality of

care provided to the aged (particularly in some nursing h o m e s a n d b o a r d i n g houses) . Present ly , responsibilities for standards of care are not explicit - both State and Federal governments are seen to have some responsibility but no one organization is able, or prepared, to follow up the wide range of issues involved. The Committee recommends an Aged Care Tribunal to which aged people or their relatives can take complaints about low standard institutional and domiciliary services. (Interestingly, the question of standards does not seem to be raised to any extent in relation to community care. Is it that as they do not cost as much the aged or their relatives do not have high expectations of thein or merely that they are only evident for a smaller part of each day than is institutional care?)

The Committee appears to have underestimated the Tribunal’s task - both in its complexity and in resources needed. They suggest initially attaching the Tribunal to the Commonwealth Ombudsman’s Office with the power to direct appropriate authorities to take action. Various legal issues and questions of authority would need to be resolved before this model could operate. Furthermore they suggest that ‘no more than two staff would be required in each of the larger States’. This appears an unrealistic level of staffing if these Tribunals are to effectively receive, investigate, and direct action on all complaints in relation to institutional and domiciliary services.

Office of Care for the Aged: An Office of Care for the Aged is proposed. Its

major function would be to ‘develop a national policy on how best to provide assistance to meet the needs of the aged’. Such a role, and that of ‘monitoring the effectiveness of the expenditure of the States’, appears to run in the face of the major emphasis of the Committee of transferring responsibility to the States. I f the States are to be individually responsible with programs locally determined and attuned to local needs, this precludes a national policy, and monitoring by the Commonwealth would seem to be an unnecessary duplication. The total proposal and function of the Office is dealt with in four paragraphs and thus a lot is not said as to what is envisaged. Two other functions of the Office do appear

positive and practical. One was that it advise on and monitor the implementation of the recommendations of this Inquiry. A new and less involved body, particularly located within the Prime Minister’s

portfolio (as recommended) may be able to ensure faster and more complete implementation than other normal Departmental mechanisms.

Paragraph 10.40 lists a final and significant role for the Office which could be broadly interpreted as ensuring that ‘aged impact statements’ are considered in relation to ‘all Commonwealth programs’. As government already considers the impact of projected programs on the environment i t should not be a great leap forward to d o the same for the aged of the nation. The Commonwealth’s wide range of responsibilities obviously impinge considerably on the 1 I % of the population who are aged. This recommendation is an interesting one following on from the wide ranging debate on Family Policy and Family Impact Statements. At first sight it would appear to be a more manageable proposition to consider the impact of current or proposed policies on the aged than to consider them in relation to families. However, the task may be just as complex as suggested by the opponents of family impact statements.

Staff Training: The need for an adequate supply of appropriate

staff and for staff training receives scant atrention apart from a broadly worded recommendation on training (paragraph 8.23). The major reorganization and reorientation proposed by this Report will require an able, trained and committed body of key personnel. An early task for all organizations involved from the Commonwealth government through to the smallest service agency will be staff development and reorientation.

Some training institutions are already reorienting their programs to meet the needs of Australia’s aged and ageing population. They should have been well aware of the issue and responding well before this Report was tabled. However, action to date has been modest and far less than required.

Staffing Implications: I t is not possible to anticipate the full staffing

implications of the Report without some definite indication of the level of funding that would be available for the new directions recommended. But taking some concrete examples: A range of professional and other staff (all hopefully with some experience in and sensitivity to geriatric work) would be required for the assessment role. The Committee suggests that more than 50 assessment teams would be needed nationally. Some of these are already in place and presumably the others would be appointed over some time period. Staff in most of the required professional and other categories would be available to meet this level of demand although their level of experience in geriatric work may be low. Adequate introduction and intensive ‘learning on the job’ would be necessary for many in the short term. The shortage of medical staff with a geriatric emphasis will be a problem but not one which should delay the introduction of the teams.

Many of the domiciliary care programs do not demand high level professional skills and these programs could be expanded relatively quickly. (Some commentators have argued that ‘service industries’ including the care of the aged are a n obvious area for expansion to combat unemployment.)

At the institutional level it is unlikely that implementation of the Report’s recommendations would decrease the absolute number of nursing home

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beds although the rate of increase may slow significantly. Overall there is no immediate employment consequence. However there are im- plications if the Federal Government should fund a uniform standard of nursing hours per patient rather than paying up to individual State determined levels as at present (Recommendation 4.3). It would be realistic to assume that the uniform level would not equate the highest level presently operating. A number of nurses employed in these States could be at risk in these circumstances. This is a difficult area as the present staffing levels are usually written into Awards or State government requirements. However as the Report points out many of these levels are inappropriate and relate more to requirements in acute hospitals - some Awards predate the development of nursing homes as we now know them although they now apply to them! (In the longer term the States would be free to determine their own nursing hours standards (paragraph 6.30.)

There would be some adjustments in Federal staffing arrangements as staff firstly move to the Department of Health and as rationalization of programs decreases the administration required. There would be a further reduction in Commonwealth staff numbers as the programs were transferred to the States with some consequent increase in State personnel.

Further Discussion: (i) Shortcomings:

Although the Report is from the Expenditure Committee the emphasis is on rational and humanitarian care as well as cost effectiveness and cost containment. The Report is generally a comprehensive and convincing document which positively plans for the better care of the aged. Its coverage is very considerable, bearing in mind the array of factors which are involved in Australia’s present maze of aged care arrangements. However, there are obviously some omissions and some issues that are dealt with less than adequately.

The Committee reports that ‘care of the confused elderly was the single problem that was most repeatedly brought to (their) attention’ (p.76) and yet this topic is dealt with in less than two pages. The proposed solutions are reasonable (‘small units in existing nursing homes and a range of community psychogeriatric services’) but are not developed to any extent. Those organisations and individuals who brought this concern to the Committee have grounds to feel disappointed and yet the vagueness here is merely a reflection of the ‘state of the art’.

Another criticism that can be levelled at the Report is the apparent undue emphasis on nursing homes as a ‘bogey’, soaking up most available resources. This is not quite fair: firstly, there will always be a number of frail elderly who need the comprehensive and medical care that only these institutions, or the even more expensive hospitals, can provide: secondly, because of the frailty, the medical conditions and the staff- intensive needs of these patients, their care will always be much more expensive than less intense domiciliary services to the more independent aged in better health who are in their own homes.

There is a t present a very considerable stock of independent units. hostel beds and nursing home beds which have been largely subsidized by the Federal Government( 15). TheCommittecdoesnotadequately address the question of continuing access to this

‘Commonwealth’ stock. Entry to nursing homes would be through the assessment teams but it is not at all clear that access to these other valuable community facilities would be similarly screened. It is reasonable to assume that i t will be a long time before accommodation developed under the suggested new funding arrangements even approaches the numbers of present stock. Thus, i f this present accommodation is not somehow more appropriately locked into the overall aged program, accommodation will remain out of kilter with an otherwise integrated system. This omission by the Committee is the more surprising considering their otherwise strong emphasis on ensuring accommodation subsidy is directed to those in need.

Another criticism is that several recommendations and their implications are not as clear-cut as could be wished.

Recommendation 4.4: ‘Public subsidy to institutions should be provided in terms of the cost of delivery of services which entails financial assistance to the provider of the services, on the basis of an assessment of appropriate costs’; and Recommendation 4.5: ‘Health authorities explore prospects for contract nursing care in lieu of benefit arrangements to finance nursing homes’.

Is this ‘deficit funding’ under another name? The recurrent cost of nursing home care is such a crucial factor that all parties involved need to have very clear indications of the implications of any changes well before they are committed. And the Report does not give enough detail for this to occur. (The separate review of fee setting for nursing homes which had been commissioned by the Department of Health was underway at the same time as this Committee and they may have been looking at that Review for some - as yet unprovided - answers.) (ii) Funding issues:

The Report falls short on one major aspect: that of costing its recommendations. This is always a very complex task but is an essential part of any package of recommendations to government. Had the Committee been forced to grapple with this difficult task they would have clarified one major question that many people have asked since this Committee was first announced.

As it is the Expenditure Committee and a t least some of the impetus for the Inquiry arose out of the Auditor General’s Efficiency Report on the Nursing Home Program (16) there is widespread concern that the not very ‘hidden agenda’ of this inquiry was cost saving and that care of the aged was a secondary matter. Had the Report shown a recommended actual increase in expenditure on the aged, this concern could have been clearly put to rest. The Committee’s emphasis however is on greater effectiveness and efficiency with whatever Budget amount is allocated.

One other comment on funding is worth noting. At paragraph 10.17 the Report suggests that ‘the relative allocation to each (program) will be a matter for annual decision’. Unfortunately, it will not be as easy as this a t least in.a low-, o r no-growth budget climate. The costs of nursing home care will still essentially be determined by the number of beds and the level of subsidy per bed. Both these factors are virtually non- negotiable (except upwards, particularly in the case of subsidy levels which are very dependent on wage rates). Thus the preponderance of institutional expenditure is pretty well locked in unless there were to

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be quite extensive additional funds made available to domiciliary care in the annual decision-making process - and this appears unlikely in the present economic climate. The two areas from which reallocation could occur would be a cessation of capital funding for further beds and from limiting the number of nursing hours per bed for which subsidy is paid, but these are not likely to enable the development of domiciliary care to any great extent. The big savings inherent in this Report’s strategy are future ones from containing nursing home growth. The recurrent funding of nursing home beds considerably overshadows all Federal capital expenditure on aged accommodation and all expenditure on domiciliary care, and it is this which is increasing significantly. This Report aims LO at least s l o w t h e g r o w t h of new n u r s i n g h o m e accommodation. The reallocation to domiciliary care would then come from the recurrent savings thus achieved in the future. ( i i i ) Administrative issues:

The non-aged handicapped who are presently served by a number of the programs discussed in this Report will be concerned to know how they are to fare under the new arrangements. I t is estimated that approximately 25% of all present domiciliary care services are provided to non-aged handicapped. The Report suggests their accommodation needs would be met under a separate program but is silent on their access to the remainder of the services. In the smaller States and Territories - and even at the regional level in larger States - good programming could well demand that there be only one system for delivered meals, domiciliary nursing etc for both the handicapped and the aged. The categorical approach to the aged suggested in the Report may need to be flexible enough to meet the similar needs of the handicapped living in the community.

Already some criticism has been voiced that the transfer of all aged programs to the Department of Health (in the short term) will result in a ‘medical model of care’. This model is not clearly conceptualized and means different things to different people. It can incorporate anxieties about an emphasis on ill health, merely in crisis or curative systems of care or about control of the system by doctors. I t can involve services being provided out from an institution rather than with a community emphasis. There can be a considerable emotive content in the concept when used by other professional groups who would suggest they, rather than doctors, should be in control.

There is n o clear ‘model of care’ a t present and merely being funded by the Department of Health does not ordain any set style. In fact a t the present time some of these programs in question are already the responsibility of Health Departments at the State level. As the Committee points out there is a need for one single Federal Minister to have prime responsibility and to overcome the present lack of co- ordination and congruence both between the separate aspects of domiciliary care and between domiciliary and institutional care. Even if there are some negative aspects of moving into the Health portfolio, it is argued they are more than outweighed by the gains to be achieved by having one Minister and one administration responsible for all aged programs. Hopefully sensitive administration will ensure that the programs are responsive to all of the needs of the aged with the social, the community, and the medical aspects being seen to be virtually inseparable. At the

State and local level the services may well be provided from a variety of health, welfare, community and other auspices. Possible Impediments:

As with any suggestion of change there will be counter arguments arguing that the situation remain as it is. Some of those who presently provide services - be they officers in presently divided government departments who administer small discrete programs, community groups which have well established and cosy working re la t ionships with program administrators, large charitable and religious organizations who have accumulated highly subsidized assets under the present arrangements or the very considerable private nursing home lobby with large financial interests involved - can be expected to argue against change and to seek a continuation of that which services their needs: even i f i t may not best serve the needs of the aged.

In this context i t is salutory to recall a major earlier attempt to achieve some rationalization of Commonwealth health and welfare programs (17). Charitable, religious and community groups which had established relationships under the then (and still now) present arrangements organized a very effective political pressure against ‘mainstreaming’ and devolution to the States. There was presumably also pressure against the proposals from within government departments and from some Ministers and backbenchers. The government of the day backed away and the matter was gently put to rest.

Too often the complex needs o f agencies and organizations can assume a11 undue importance. The means become ends in themselves rather than merely the process by which the objective is achicvcd. A reminder is needed that the objective of this now vasi system is the well-being of elderly citizens. Many of the -recommendations of this Report make this objective much more definite than d o present arrangements. The lobby groups which will now be responding to this Report need to ensure that the challenges and proposals they advance are for the benefit of the aged and not merely to ensure the continuation of present ways.

I t is difficult to anticipate the likely reactions from the States to the Committee’s recommendations. I f the States feel the Commonwealth is merely abdicating responsibility in an emotive and costly area without any guarantees of ongoing financial support the reaction is predictable; and here a lot will depend on how they are perceiving the new hospital funding arrangements this far down the track.

The Committee has sought to overcome at least some of the likely fears of the States. They have recommended:

that the Federal programs be rationalized and that significant cost containment procedures be introduced before any attempts are made to transfer responsibility;

some immediate cost savings to the States by the removal of present cost sharing requirements;

a five year negotiated agreement with each State;

ultimate absorption of these new financial responsibilities into Tax Sharing arrange- ments.

Certainly aged accommodation and services sit more neatly with State responsibilities. To be effective they

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must be part o f the broader health, welfare and housing services of the States. And the local responsiveness which a State government is able to provide must be more appropriate than is possible from a remote central system which has to enswe services on a uniform and nationwide basis.

Hopefully this dilemma of the level of government responsibility can be positively resolved this time. Ultimately the public funding of these programs all comes from the same source - the community at large.

I t seems unlikely that this Report could coalesce the elderly into a coherent ‘elderly lobby’ - the elderly are a diverse group in the community with many interests and many different needs. Furthermore, i f these recommendations were adequately financed and effectively implemented, i t would be likely that more elderly would be better served under these provisions than under the present schemes.

There is a further impediment to the suggested recommendations going ahead, which the Report summed up in these words: ‘Votes are to be gained by opening buildings and having pictures taken while cutting cords’. Federal Ministers and Members of Parliament too often wish to keep control of the purse strings - to enable them to gain political points by announcing or opening a new facility, and SO that inducements can be offered to marginal areas for party political purposes. This ‘brass plaque mentality’ can block other rational arguments for transfer of responsibilities. But it constitutes a cost which the country cannot afford and should not stand in the way of improved services for the aged.

The Committee is pragmatic: They have given ‘a framework for the future’ wi th the three distinct stages:

restructuring of programs and funding

negotiation with the States; transfer of responsibilities to the States.

arrangemen ts;

They accept that government, for whatever reason, may not proceed to implement all three stages but point o u t that achievement of the first objective would result in significant improvements. One can only endorse this sentiment:.a restructuring of the present complex and non-interdependent range of ad hoc programs into a rational and integrated system managed by the one Minister must be to the benefit of the aged.

Obviously the Committee saw more gains being achieved by progressive implementation of all three stages.

On the more positive side, the Report was prepared by a Committee consisting of members of the three major political parties. During this very considerable exposure to the present arrangements they obviously saw the need for radical change. Hopefully the non party basis of the Report will facilitate its serious consideration by government and the parliament.

The Report had very little discussion in the Parliament when tabled on a very busy day. Nor did it receive any significant media coverage. However protocol on Parliamentary Reports such as this requires that government respond to the Report within six months, usually by a Ministerial speech indicating what - if anything - is to be done about the findings and recommendations. A major working group of senior officers will be now considering this Report so as to meet this deadline.

Timeliness: The Report shows Australia as having a complex.

fragmented and expensive system of aged care with responsibility shared between too many, often vested, often conflicting interests. A system such as this needs major surgery and the Committee has opted for significant changes. But several earlier reports to government on the aged have said some of this before. The diagnosis of the present condition is pretty well agreed as is much of the preferred treatment. The value of this Report is that it establishes in very considerable detail the present problems, and the processes by which required changes can be achieved. They have set out to make the Report ‘implementable’ - giving considerable attention to discussing their recommendaitons with those involved, making their recommendations distinct - maybe not bite sized but at least digestible - and establishing an overall strategy and time frame. They have suggested a body to oversee the implementation of the Report and that Parliament review progress and be advised of further plans.

Now all of this is positive, but is not of itself enough to guarantee that government will act on the Report.

The important other ingredient is timeleness and it may just be that this Report is timely. Community and political concerns about ageing are now emerging: matters such as the increasing number of the aged, dissatisfaction with present services, with the fragmentation 6f responsibility between Federal and State governments, with the mismatch betweeen institutional and domiciliary programs and the cost escalation of present programs have all combined to force ageing onto the political agenda. Previous Reports have not been totally lost causes, they have ‘softened up’ the issues for consideration and many more now believe that major changes are inevitable than was the case when the earlier reports were released. Furthermore, responsibility for aged care at the Commonwealth level rests with two Ministers, both of whom are strong on cost effectiveness and cost constraint; and both keen to make their mark. One is specifically vested with responsibility for ensuring improved co-ordination and forward planning in matters of social welfare policies. And the recent transfer of hospital funding (following the Jamison Committee Report) provides a current example of the ra t iona le f o r increasing Sta te government responsibility.

Thus this Report comes at a good time and may just be the catalyst needed to get a major reorganization of aged care under way. I t is also significant that a recent spate of reports prepared for the State or Territory governments have pointed up many of the same issues as has this Commonwealth report (18). The Questions Remaining:

It is difficult to disagree with the major principles of this Report. It argues for a restructured and well developed system of aged care that is rational, integrated, effective and cost efficient. But to achieve this, significant changes are necessary in all parts of the present system . . . and these changes are generally interdependent. I f some changes are implemented and other complementary elements are left unmoved, the end result could be worse than even the present ar- rangements. For instance, the aged would be disad- vantaged i f government ceased to fund additional nur- sing home beds without a simultaneous increase in ef- fective domiciliary care and in the availability of low

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cost accommodation. A significant and adverse flow- on effect would be to increase the market value of private nursing homes and consequential pressure on government to increase the bed subsidy rate to com- pensate investors. Another worrisome example would be i f the Federal Government rapidly accepted the recommendation to transfer responsibilities to the States without firstly putting the programs in some order and then guaranteeing adequate funding.

Many of the recommendations must be regarded as a 'package deal' and not open to individual acceptance. And this is the big area of concern: Whether government will accept and fund the total package or merely take those cost saving aspects of the Report and ignore the 'expenditure' recommen- dations. In the present economic circumstances government can too readily take this latter course. k n d this is the major issue worrying those who have considered this Report in detail., Unfortunately, i t is a question that will have no answer until Cabinet has taken its final decision on this Report.

Conclusion: This Report is a comprehensive review of the past

and the present, and a vigorous blueprint for the future - and its timing is well nigh perfect. I t chal lenges the complex arrangements and relationships presently existing within this major industry and as such will be seen by some as a threat. But for too long the care that the aged can receive has been determined by established structures and

arrangements rather than by the needs of the aged. I t has been a classic example of the tail ('the industry') wagging the dog (the needs of the aged), of the means becoming ends in themselves.

Subject to some few caveats (and these mainly relating to funding guarantees) the Report provides a model for rationalizing and improving the present arrangements and significantly aiding the well being of Australia's aged. I t will be interesting to see i f this is the government's objective for its aged care programs or i f the Report merely provides the rationale for cost containment or even cost cutting.

Acknowledgements Many people have helped my understanding and

consideration of the kIcLeay Report. At the present time most discussion between persons involved with aged care sooner or later turn to the Report and its implications. This makes the task of acknowledging individual input virtually impossible. However the effect of these many and varied contributions is now evident in this Working Paper.

I thank all who have helped me in this process. Special thanks go to Dr Anna Howe, Dr Sid Sax and Dr Hal Kendig for their comments and support, and to Jennifer Burgun who typed earlier drafts and this final

(FOOTNOTES) These include:

Australian Government Commistion into Poverty (The Henderson Report). 1975

Australian Government Social Welfare Commission. Care of the Aged Rcport. 1975

Report of the Task Force on Co-ordinarion in Welfare and Health (The Bailey Rcports), 1976.9 1977

Report of the Committee on Care of the Aged and the Infirm (The Holmes Report). 1977

Report of the Joint Working Party on Hostel Accommodation. 1980

Report of the Auditor-General on Commonu~ealrh Administration of Nursing Home Programs, 1981

Report from the House of Representatives Standing Committee on Expenditure: Review of the Auditor- General's Rcport. 1982

An internal Committee of Review of aged persons welfare programs chaired by Mr John Hodges MP.

Dr Bruce Ford, Director of Rehabilitation Services, Alfred and Caulfield Hospitals. Melbourne. Now Dr Anna L. Howe. Research Fellow, National Research lnsrirute of Gerontology and Geriatric Medicine, Mt Royal Hospital. Melbourne. See, for instance. Anna Howe. 'Reports Now - Action When? The Implementation Gap in Social Policy'. Paper presented to Social Policy Conference, ANU, 1982. Aged or Disabled Persons Homes Act Aged Persons Hostels Act State Grants (Home Care) Act

Senior Citizens Centres HomeCare . Welfare Officers

Personal Care Subsidy Nursing Home Benefits

National Health Act Nursing Home Assistance Act Extensive Care Benefil

Delivered Meals Subsidy Act Home Nursing Subsidy Scheme States Grants (Paramedical Services) Act Domiciliary Nursing Care Benefit

Common\vealth Department of Hcalth. Kelative cost) of hotnc care and nursing home and hospital care in Auslralia. Canhcrra. 1979. Brotherhood of St Laurcncc, Royal District Nursing Service. 'Evaluation of the service relcvance and cost effectivcnesr ?f alfirnative staffing pattern for domiciliary nursing scrvices , Part I. Melbourne. December 1981. D. Kinnear and A. Graycar. Family Care of Elderly People: Australian Perspectives, Social Welfare Research Centre. Sydney. 1982. Senate Select Committee on private hospitals and nursing homes. Health Commission Working Party on Extended Care of Aged or Disabled Persons. Victoria. July 1982. see Robert L. Kane and Rosalie A. Kane. 'Alternatiyes to institutional care of the elderly: Beyond the dichotomy. The Gerontologist (US), V01.22. No. 3. 1980. Table 4.8, p.38: citing ABS August 1980 Survey of Housing Occupancy and Costs. Task Force on Co-ordination in Welfare and Health. First Report. 1976. paragraph 7.39. p.88: statement of intention of Sfate Grants (Home Care) Act. 1969. At June 1981: 30,950 self contained units. 33,684 hostel beds and 14.578 nursing home beds had been provided under the Aged or Disabled Persons Homes Act and the Aged Persons Hostels Act. Report of the Auditor-General on an Efficiency Audit. Commonwealth Administration of Nursing Home Programs, February 1981. Task Force on Co-ordination in Welfare and Health. First Report. 1976. Some of these are listed on pp. 108-109 of the Report.

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