History of the Domiciliary Care movement in South Australia and its evolution from the 1970s-80s. Richard poses questions to be resolved in Dr Anna Yeatman’s Review of the service as to how best to structure care for younger people living in the community

1989 – Submission to the Domiciliary Care Review Seminar – Flinders University

1989 Review into Domiciliary Care Services in SA

This current Review by Dr. Anna Yeatman, I believe provides an excellent opportunity to build on the envious record of Domiciliary Care to explore the requirements of younger disabled client groups, and to re-align the way these requirements are met. These seminars and the Review provide an opportunity for new ideas to be considered in a non-threatening atmosphere.  I am sure no-one doubts the sincerity of those working to assist people with disabilities; the debate is about the way these new requirements are best met.

The ideas I am presenting today are my own. I should also make it clear that I am not a receiver of Domiciliary Care services. I am, however, proud to say that I have worked within the Eastern Domiciliary Care Services from 1975 to 1980.

1970s beginning of Domiciliary Care – avoiding institutionalisation of aged people

In those days the frail aged were the clear target population for Domiciliary Services. The espoused goal was to keep people in that group from unnecessary institutionalisation. There was very little money, resources or staff and expectation was confined to a nine to five, five-day a week service.

The multi-disciplinary approach and package of available services of D.C.S. were envied by many organisations here and overseas. Paradoxically, the success of those early services have become the cause of many of the problems which we have heard described during these seminars. 

The community and governments realised that there were less costly alternative costly solutions to placing people in nursing homes. The number of clients and more importantly, the depth of service required to keep more severely disabled people in their own homes, began to rapidly escalate.

Gap in service provision for severely disabled younger people

I believe the need for a wider and greater depth of service, has been a greater problem than the increased numbers.  Although Domiciliary Care in the 1970’s assisted younger people with severe disabilities, there was little expectation beyond minimum assistance and the loan of standard items of equipment. Most younger people were expected to cope within their own family resources or head for the Home for Incurables when that failed. In fact, in the Eastern Domiciliary Care Service, the frail-aged eligibility criteria was strictly adhered to, for fear that the clients of the nearby Spinal Injuries Unit would exhaust the scarce resources at the expense of those frail-aged people.

As Domiciliary Care services were provided and promoted, community attitudes changed and people directed more responsibility towards these public, government-funded services. In the early eighties, the Commonwealth introduced policies aimed at limiting nursing home beds and the need became obvious for planned twenty-four hour, seven-day a week services in the home became obvious.

1980s changes to Domiciliary Care structure and clients for in-home care

In the early eighties, Domiciliary Services also moved from a community-based management structure to control through regional hospitals. The Medical Directors of these services at about this time also changed their professional base away from a rehabilitation emphasis to geriatrics. Then in 1985, the introduction of the Home and Community Care (HACC) program dramatically changed Domiciliary Care directions, goals, target groups and the delivery of service.

People with disabilities require a package of services in order to overcome the difficulties of daily living which their disabilities have caused. If one element of that package is missing or inappropriate it very often negates the value of other assistance.  There is for example little purpose in introducing employment opportunities to people with disabilities if the person is unable to be got up and ready for work by a certain time. There is also not much point in getting the person up and smartly dressed ready for work if they cannot get to their place of employment, because the element of transport has not been available or organised within the package of requirements for that individual.

The Dom Cares of S.A. seem to me to provide the best base for the delivery of in-home care services to people with disabilities.  But to improve this base, the Commonwealth and State and SA Health Commission bureaucracies must be more responsive to the requirements of consumers.

Family and disability stresses

Although it may be changing, our society is still organised around the family.  Our city architecture, education and financial institutions have been built with the family at the centre of community relationships. The speedy 20th century has brought many changes to family relationships in roles and work patterns of men and women.

People with disabilities and their families/carers are integrally involved in the fact of disability.  Disability imposes itself onto normal aspects of daily family life. It slows mobility and adds additional stress onto family energies, budgets, recreation, social opportunities and career aspirations.

What do we need to alleviate these additional stresses?

How can we provide a flexible, balanced range of choices?

In the brief time left, I want to put forward four major requirements of people with disabilities, and raise some questions for discussion of how we may meet these requirements through Domiciliary Care:

  • People require not only advice, but also hands-on help. How can we provide assistance in the least restrictive way? Sometimes, this assistance is family assistance, rather than specific to the person with a disability.
  • What depth of service can people expect? Is Dom Care to remain basically for frail aged people or should it to be provided with the funds to widen its charter of care of younger people with severe disabilities?
  • Should that care be provided equitably for all diagnostic groups? Should people with the interest and skills be given the means to solve their problems independently?
  • Control of their own environment and activities

What control can people exercise over their own environment and activities?

  • What degree of control can people exercise over how, when and if services will be provided to them? This includes weekends and after hours choices?
  • What degree of participation should people have in the planning, delivery and evaluation of these programs?
  • How do we achieve effective consumer participation right throughout the bureaucratic network? 

Everyone seems to agree that there is value in consumer involvement. We hear a lot about training of professionals, but what about a financial commitment to the training or ‘skilling’ of consumers, parents and families?

How can people get reliable assistance and choice of care workers?

  • Do we need to maintain the principles adopted by some Dom Cares of rotating staff?  Should we be employing more casual staff, recruited from the locality in which they may be expected to work?
  • Where do the District Nurses fit into the organisational structure and who should lead the organisation?
  • How do we get the most appropriate, efficient rationalisation of professional skills and hands-on help?    What is the appropriate balance between the chiefs and Indians?

Access to equipment and environmental modifications

  • Are we making the best use of available equipment? How do we convince the bureaucracies that the provision of appropriate equipment is a functional and economic necessity?
  • Should we be extending the range of equipment to aid people with disabilities and their carers to have more independence and maintain better health?

I don’t believe we can continue with an Oliver Twist mentality by just asking for more. Spending of the disability dollar has been going up every year. The questions is, have the positive outcomes for people with disabilities increased at the same rate?

I believe this Review provides an opportunity for people with disabilities and the people who work in the Dom Care Services to re-orient its priorities.