Fault-lines show Commonwealth cannot effectively run aged care from Canberra, expert Hal Swerissen champions change

From the mid-90s, Hal Swerissen has been an advisor to both State and Federal government. For over thirty years he’s worked in all parts of the aged care system, and currently, working in academia and alongside seniors daily, he shares that gone is the time of “admiring the problem”. Explaining the roadmap to the cracks, alongside pragmatic and sensible solutions to work towards a system that works for everyone involved, government, seniors and sector, should be brought forward. Stepping into the space of why and the solutions to meet them is what advocates and experts are calling for. But the solve hinges on a listening government. For decades-experienced experts and leaders in aged care, listening has always remained integral. In this time of fault-lines, to hear from people who have spent decades living through the up-and-down functioning of the sector, what has and hasn’t worked is vital. Reform can and must pivot from those that earnestly, sincerely and credibly can speak to what should change, these voices can and must be seen as an invaluable resource to move forward. Humility is warranted from all parties, especially government, to step into corrects that will mean a robust and sustainable sector for the years and sizable demand to come. As well as the thousands of lives impacted, young and old, client and staff, public and private alike.

The disconnect begins

Advocates, state ministers, and seniors stuck in hospitals have been horrified at the situation in the health and aged-care systems. With thousands of seniors stranded in hospital, blatantly showing an ineffective system, how did Australia find itself here? Swerissen starts by casting the viewpoint back, to a time long gone, the beginning of the 1990s.

He shares, “there used to be planning ratios for the number of people over 70, there was a bed ratio of 10 per cent. What used to happen was bed licenses were allocated on the basis of the planning ratio but that’s dropped off now”.

“Instead, the government has adopted a market approach to aged care residential providers, what that has done is made a patchy planning approach.”

“The previous planning was based on regions, area-based planning, now it’s market based, so for providers, it depends on whether you think there’s a market for an aged care facility.” Facility viability has sadly become a bleak reality for sincere providers contemplating building in more rural areas within the current model.

The initial pivot came in the form of government shuffling responsibility, “there was a period up until the early 90s where states had responsibility for aged care, it was a significant responsibility and they were a partner in the process, then the Commonwealth moved to take over that responsibility for aged care, that’s been the case for 30 years now.”

He shares, “the last step was taking over the home community care program and the creation of the community home support program” And now too the Support at Home scheme.

“So it now has total responsibility for aged care, and also has 40-45% of funding for hospitals, but so do the states”.

And the result is what we now see, “so all that’s all happened over the last 30 years and it creates a disconnect between the Commonwealth and the states.”

Why it’s not working

Swerissen explains that as management ascended through government, the building blocks for fault-lines were laid because of a growing distance of visibility, insight and management, “what is happening is that as people age and become frail and need increasing support, using hospitals and health services, and aged care services, they are doing that at the local level, but there’s no coordination of that at the local level.”

He shares what providers, seniors and loved-ones have been saying for years, the business of ageing happens in suburbs and local neighbourhoods, proximity is needed for clear coordination. Swerissen affirms that has not been happening, “the only real coordination that occurs is at the level of the States for hospitals and, even higher up, Commonwealth for aged care. It’s a central national coordination.”

Swerissen reminds that this model was not supported by the Chair of the Royal Commission. Judge Pagone lent his insight to champion a very different approach, “between Lynelle Briggs, a senior public servant and Judge Pagone, there was a very unusual split, especially for a Royal Commission.”

“There were essentially two reports and recommendations for how aged care should be managed, one from Pagone and one from Briggs”, Swerissen highlights.

“Pagone wanted a model where a separate agency was set up to manage aged care which had regional structure. The regional structure would have been a much more managed approach. And Briggs wanted to retain the existing Commonwealth model.”

“In the end the Morrison government agreed to the Briggs model and the Labor government hasn’t revisited it and has left it there.”

The market model

Swerissen explains that “the Briggs model is essentially a market model with central regulation and central funding and almost no regional coordination. No regional planning, no regional coordination, no sitting down with the local hospitals and sorting out what’s needed.”

He shares that, “the result is that you have a marketplace model, centrally funded, then regulating it centrally to try and prevent the sort of concerns that were there for the Royal Commission on quality, not a model based on planning and management and proximity.”

This model, he explains, means, “so now, effectively, planning and management is in the hands of the individual consumers. You get an amount of money, have to go find a home care or residential care provider, and you’ve got to find your way through it.”

“There are lots of complaints about how seniors have to do that”. Provider heads are now also increasingly voicing the fallout from this model, thousands of seniors and loved ones are trying to figure out the individual new system, and the complexity is felt by sector leaders and staff too.

For seniors and providers, “there’s no one stop shop, if you live in Ballarat, or Bowral, or anywhere else in the country, no easy way to figure out a plan for seniors” and additionally, how providers are to individually connect, customise and work with clients.

Scrambling at the local level

The disconnect between Federal management and not knowing what’s happening on the ground locally has meant increasingly situations of seniors, provider leadership and staff, and local hospital staff scrambling for resources reactively.

Swerissen names what people across healthcare and aged care have noted for years, apart from planned moves into residential aged care, “there is a second way, which is very common way of getting there, a senior has an event, a stroke, and they end up in hospital and then going home isn’t a great option anymore. Then people and loved ones end up scrambling for a place.”

“You have hospital social workers, and whoever else trying to find a place, alongside providers, and then a senior is put on a priority list, and the wait begins. Neither the planned method or event process are effectively managed at the local level at the moment. It’s a very messy process.”

Swerissen has heard the call from seniors, from provider leadership, from the sector, “the rhetoric of rights and choice is great in theory but it’s not actually done [or supported].”

“A more managed model would probably produce a better result. It would mean services being more likely to be provided in the right place at the right time than what’s currently happening.”

Another result from the market model is that hard-working, brilliant and earnest small providers are feeling squeezed to make ends meet, both in home care and residential aged care. Swerissen echoes the sentiments of small provider leadership who have been fighting to have financial viability to provide excellent aged care with a small number of beds, “when I started in the 90s the viable size of an institutional residential aged care facility was 30 beds. Now they’re commonly being built at a hundred to a hundred and fifty.”

“Problematically, the market model is leaning towards big box institutions for people who are older, living in very institutional environments”, he says.

“It is high variable, there are some terrific big providers, but there are poor performers, who are very boring and institutional and that’s not great.”

It’s time for solutions – regional hubs

After laying out where the sector has come from and where it’s at, Swerissen is adamant there must be a shift to putting forward pragmatic solutions that government can listen to and implement. If they so choose.

There are no rose-tinted glasses for this veteran of over thirty years, he is ready for a bleak laugh, when it comes to pivoting to solutions from where the sector is currently, he echoes many sector leaders, “if you ask me how to get from here to there, I’d say, don’t start from here”.

“We’re in a place where I wouldn’t have started from but we are where we are”.

Swerissen is clear, “practically I would set up a regional structure. I would create this regional structure, and the logical place for the Commonwealth to start do that is, they have a whole set of agencies called Primary Health Networks and there are around 32 of those around the country. They deal with GPs, primary care and prevention, they exist.”

“They have offices and they have staff, and they’re spending $1 billion on those.”

Swerissen advocates for a system that works closely with local provider professionals who are on the ground, providing services, currently swamped by paperwork, “these networks and offices provide a regional structure from which the Commonwealth could give aged and probably disability care and responsibility to. For planning, coordination, working closely with the providers, in making sure they get the funding and services which are needed locally.”

He goes a step further, “And if they were especially keen, they could provide a consumer facing element to those offices, providing the option for people who did not want to manage their own aged care, they could willingly assign over their rights to the staff in the primary care network, and their services could be managed for them.”

For the providers who have felt the seismic shift in administrative burdens, on top of compliance and regulatory check-boxes, Swerissen recognises the need to alleviate resources wasted, “And then seniors and providers wouldn’t have to do all the bureaucratic work that they have to do at the moment.”

Eliminating bureaucracy, getting back to care

For seniors and providers, the administrative burden has reached stratospheric levels. Increasingly provider leadership and staff are flabbergasted at the amount of time that has to be diverted to paperwork away from service provision.

Swerissen sees setting up a regional structure through the primary health networks as, “eliminating a lot of central bureaucracy and in devolving it to those primary health networks, they would get local management.”

For countless aged care providers, there has been a growing frustration at Federal government seemingly so disconnected, that policy hasn’t gotten close to effectively supporting the pragmatics of excellent care. Swerissen advocates that regional and local management can mean, “sensible planning and coordination. [Govt] People who actually know what’s going on locally, and to give seniors the option to opt out of the bureaucratic burden of these packages.” And by extension providers too.

Providers and Swerissen have both heard from seniors, “so many people are saying, I just want the services, please just give me the services.”

He notes the situation of basic level home care, “800,000 people and more, are just using two to three hours of basic services like cleaning, laundry and garden, they’re being supported through the community home support program, why would you go to a package model for that? It’s nuts. It’s a bureaucratic nightmare.”

Swerissen champions local government working directly with the local provider leadership to sensibly and strategically pre-empt and respond to changes for the local population. Proximity and relationships are key to addressing the huge lift of meeting the demand here and nearing aged care.

He suggests, “what you need is an agency at the local level to say, I’ll have a contract for 19,000 people who are using this program, and I’ll manage that and I’ll get those people their service, and we’ll run the budget for them, and they don’t have to worry about individual packages and so on.”

“And these agencies/primary health networks would be able to develop good relationships with aged care providers. The local agencies could be given low cost financing to build/partner with local providers to build the necessary beds that they don’t have in their area for example.”

Swerissen affirms the exhaustion from seniors and providers in tackling the thousands of individualised packages in the current model, “it’s just bureaucratic overkill for individuals and providers.”

“I run groups for older people, I hear stories every day from seniors where they have a spouse in hospital with a stroke, and ‘we’re trying hard to figure out what to do and we’re trying to sort it out with the social worker, and we don’t know how this system works, and we don’t know who to go to.’”

He echoes provider sentiment, increasing advocacy groups and providers, who are dealing with the fallout from government systemic complexity. The admin mountain builds, which is in and of itself a barrier to efficient and quality care.

Based in reality

Swerissen as a veteran in aged care has shown his commitment in the years he’s persevered. And he reaches out to seniors, provider leadership and staff, and other sector professionals, in acknowledging that perseverance is a requirement of seeing out times of change and fault-lines in the sector.

Far from glossy magazines, he honours the hard-work of providers and the stress of seniors by not sharing hollow-promises, this current time will likely be, “for a while, then it’s going to need another major overhaul.”

He is pragmatic and transparent in acknowledging the challenges for providers to tackle the systemic consequences of policy, “under the current model, every person who comes in being an individual consumer, with their own accounts, having to be completely met under all the regulatory requirements the Commonwealth has in place, then having to deal with administrative burden of individualised funding, this creates a cost for providers.”

“And that cost is significant”, he recognises.

He shares, “there is a cost which providers are bearing just on administration of individuals accounts and the regulatory burden that they’ve got.”

“That is a significant challenge for them.”

And it is important to articulate, he notes, “that has been created for them by the Commonwealth’s model.”

And yet the pivot to solutions, and the humility to take them onboard, is critical for government, “there are savings which could be made in terms of efficiency.”

Supporting innovation from local proximity

Swerissen affirms what providers have been wrestling with, for high-performing providers, earnest in providing care in joyous and holistically-human facilities, “the industry really isn’t a very effective market in the sense of letting really efficient providers get on with it”. Advocates and providers are adamant that needs to change, for everyone’s sake, seniors, loved ones, younger generations and the sector.

The government, Swerissen notes, could be able to take the pedal off the compliance pedal if they had insightful, local visibility on providers and seniors. This would also allow a crucial blossoming of a key ingredient in any industry, desperately warranted in aged care, innovation.

“Ironically, the government’s obsessed with efficiency but not with innovation.”

Swerissen advocates for the Federal government to, “simplify and localise the model, have a sensible approach to choice, enter into a commissioning-based block model, move away from an individualised package model and encourage innovation, and simplifying the administration and regulatory frameworks.”

Investing in local models of running aged care could mean, “government people who know the providers well and are on the side of the consumers. It could be a brokerage model.”

Relationship over regulation

He pinpoints what leadership greats have espoused for centuries, relationships based in earned trust and proximity make for strengthened points of management, “having government on the ground, who know the providers and what they’re doing, so then it replaces the regulatory framework, all the rules, paper and reporting because personnel on the ground know the providers and can assess efficiently for quality and safety.”

Swerissen unequivocally notes, “the commonwealth needs to have people on the ground who actually know what’s going on, and that’s not happening at the moment.”

He recognises the challenge before providers, “you have to have a pragmatic approach to all this, the government has increased their staff costs, regulatory burden, we’ve increased their costs because we require them to administer individual packages.”

“All the costs are real. We need an industry model which is more streamlined, more efficient, more locally managed to deal with those issues.”

Swerissen says, “what we’re getting is a lot of admiring of the problem [within and without government], everybody is identifying issues, what is less there is how to fix it. The fixing of it will need to go out of the current framework, the existing framework is fundamentally broken.”

For Swerissen, seniors and sincere sector leaders, the opportunity is for the government to enter into discussions. Humility has a place in great leadership, to come alongside those that have committed decades to the industry is a resource and way forward, to bring about change that results in a sustainable, robust and regionally led aged care industry.