Research into early innovative home care services for aged and handicapped people started in South Australia under the Whitlam Government funding

18 October 1977 at the Southern Regional Geriatric and Rehabilitation Advisory Committee, Flinders Medical Centre

Richard advocates for consumer voice to improve service outcomes and re-balance who gets the benefit

My subject is “Who gets the benefits in services?” The question could be asked broadly, and I wonder how many of you feel that ‘service’ is a bygone word? Today I will narrow the question to that of the ‘health services’.

Services are paid for by the community in the end

When we speak of ‘service’ we are really equating it with money and the size of slice of national cake which is applied to that area. Before the private organisations take me to task over that statement, I would remind them that the experience of Medibank has dispelled any argument that Government services are the only expenditures con­cerned with the “National Cake”.   

Whether one shifts the balance of payment between the private or public arena is of little consequence to the community at large. For it is broad society which eventually picks up the tab. This fact should be paramount in all our thinking, with perhaps the exception of multi-nationals and other foreign owned concerns, that Australian society is not a fragmented object to split into this, that and the other interests. It is like an heirloom or a valuable painting which requires a whole atmosphere of care and concern.

Salaries drive services

If we agree that service is dependent on money, including the voluntary sector, then the fact that approximately 75% of the health budget goes in salaries should tell us something. That remaining 25% then has to be divided into equipment and running costs for those people drawing the salaries. One cannot imagine a doctor without a white coat and stethoscope or perhaps today an electron microscope, or physiotherapist without at least an ultrasound. There is a further erosion by the inflated cost of medical equipment needed by the health professions.

Innovative aged and disability home care service

Regional Domiciliary Care Services (Dom Care for short) started some three years ago as a new concept to Australia with funding from the Whitlam federal government. These services focused their attention on the broad needs of elderly and physically handicapped people to assist them to remain in their own homes, and therefore, reduce the call on expensive institutional care. In a short time, the influence of these kinds of organisations are being felt by the provision of these types of services, with an example from Eastern Domiciliary Care Services where I am the Administrative Officer. Dom Care provides the following twelve services to its many clients to assist them to stay in their own homes:

Aids on loanGeriatric consultationsLinen service
Chiropody/podiatryHome helpRespite admission to nursing home beds
Day hospital attendanceHome modificationSitter service
Disabled living assessmentLiaison with Meals on Wheels and the Royal District Nursing ServiceSocial work

Impact of home care support

In our own region for the first time in a number of years Northfield long stay wards have vacancies and nursing homes in our area are advertising vacancies in the daily press. Home Help, something everyone wants but do not necessarily need, is the biggest expenditure.  Currently there is a study which at this stage may show that Home Help has little effect on the task of keeping people from nursing home or institutional placement.  There is, of course, no denying an improved lifestyle from receiving home help. Even in services as direct as this, only 8% is going directly to the client.

Why should we be concerned other than for humane reasons, to keep people from institutional care? These statistics come from Eastern Domiciliary Care Services (EDCS) files in 1975/76:

Total Referrals 2,626
Patients admitted to nursing homes 199
Patients deceased     524
Inactive cases   332
Active patients       1,571
Patients receiving home help and sitter service   578
Patients receiving linen service   71
Patients holding equipment      968

Compare these 1975/76 statistics with Royal Adelaide Hospital (RAH) figures. Our Dom Care service with a staff of 30 can maintain 1,500 active cases at a cost of $5.00 per case per week. The RAH requires 6,000 staff to care for 1,000 beds at a cost of some $800 per week per bed. The cost of nursing homes is difficult to obtain, but we would estimate that patient cash and Government out-goings would be approximately $200 per week.

Value of keeping people at home rather than in nursing homes or hospital

It appears that by keeping some 60 people from a nursing home, our entire budget is justified. The type of regional domiciliary service which is operating here in South Australia seems a rare phenomenon, and one which appears unlikely to get encouragement for replication in the other States, at least in the present financial climate.  Those involved in the delivery and consumption of these health services know and can see their value, but these people do not necessarily make the decisions about their existence or their financial share of the overall health budget.

Hopefully this problem area in the question of services – planning and administrative sectors being often separate from the delivery and consumption arenas will be alleviated with the new South Australian Health Commission.

Employing handicapped people to serve handicapped people

Recently I talked with a senior official from the handicapped division of the Commonwealth Rehabilitation Employ­ment Service and inquired how many handicapped people they employed within their branch. The answer was none. He looked surprised when I said I thought that was hypocritical sending fit people out to ask other employers to give jobs to the handicapped.

Who makes decisions about services?

Two separate groups appear then in the politics of health decision-making:

  • those with the power and little field community experience, and
  • those without visible power but with the ability to evaluate the delivery of service through daily experience of it.

This latter group includes not only the health professionals of the paramedical side but the numerous aid and support staffs.

Health consumer’s role in improving health services

The most silent of all until now have been the partakers of the health services, the consumers. They truly “get” the services, both in the terms that today one gets what one asks for, and that service, in our times necessarily has to be a word tempered by reality. These people who are the clientele of health services provide a reservoir of energy and insight which has yet to be tapped by the health planners.

I advocate the participation of health workers and consumers in planning of health delivery systems, not because they have the right to democratic participation for its own sake, but because they have the power to continually evaluate the delivery of the service from our national cake, and to hold planners and delivers accountable for their functional product. I believe that there is little in this suggestion to threaten the people at the planning level, unless their priority lies outside direct delivery of service, that is research, teaching, etc.

Improve efficiency with voice of service users

What is happening at the moment is a gross imbalance in these participating parties. As in all economic sectors, the large institutions are the ones who are listened to and often at the expense of the Cinderellas who are busy sweeping their fireplaces and justifying their daily work load. The large and small health systems should have to argue for their rational share of the fiscal cake in terms of function and value to the community. The present policy of rewards for big spenders with matched budgets does little to encourage the efficiency of saving money only to find reduced rewards. A more active voice from receivers of service could redis­tribute the health cake towards more equitable provision for the numbers receiving specific services.

Role of professional services in protecting their interests

This theoretical proposition is difficult to see in practice. Who is the consumer of health service? Is he a member of a collec­tive bargaining group, like the members of the paramedical and medical professions?  It is easy to see how interest groups formed to protect their members’ interests distort the distribution of the national cake.

Consider for instance the rational case a social worker has for a pay rise in comparison with other professional people of roughly equal status and job demands. With the help of established line of power and communication, such a claim of the national cake seems trivial to object to and valid enough to grant.

Need for comprehensive consumer voice

Consider equally the case of the 21 year old woman who has cerebral palsy photographed in the paper last week, who contributed to the cost of her own electric wheelchair through saving her invalid pension, and made up the difference through the charity of a local service club. She had no lobbying group on her side, little training or experience with using systems to obtain a desired goal. It is possible that that electric wheelchair will satisfy her wishes and she will make no further demands on the national cake, nor further forays into the system which from my point of view are contributions.

The consumers of health services have one binding quality in common – their transiency. However, except for the elderly and disabled, the most continuous presence in the health delivery system are the paid people. The difficulty in establishing equity in health evaluation lies in awaking a sustained yet comprehensive voice in the consumer sector.

Who gets the service?

This must come about – if for no other reason than to stop the erosion of the word “service”. It has become one of those confused English words that can be applied as a noun or a verb to mean many things.    Let us ask “Who gets the service?” to each of these meanings of the “service”:

  • Service as employment – Within the health delivery sector who obtains the 75% salary cheque?
  • Service as a branch or department – The big, the shiny, the new, the dramatic. The pride of the national cake is in these but think how far it is from the single individual who feels neither shiny, new nor dramatic.
  • Service as work done or duty performed for a master or superior – In our secular, money-oriented society, it is difficult to conceive of the consumer as the master of the professional health worker.    The Christian example of washing other people’s feet has by and large faded. Even with Medibank, Jesus would quickly receive a bill from “Peter the Podiatrist”. Our whole health language provides props of superiority which help reverse the power relation­ship, with words such as “patient”, “invalid”, etc.
  • Service as an activity carried on to provide people with the use of something – This may come closest to being the current working definition of health service, as it focuses on use or function of the commodity.
  • Service as benefit and advantage – Working within the health service structure holds many more rewards, socially, politically, and economically, than receiving it.
  • Service as beneficial, friendly, helpful action – I look forward to the time when our health services reintroduce this lost phrase back into currency: “We are at your service”.