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‘The market alone is not the solution to problems of quality’

The notion that aged care quality will be driven by consumers making choices and exercising control has not been demonstrated overseas, write Michael Fine and Beatriz Cardona.

The Commonwealth Government has made clear its goal to establish a single quality framework covering aged care – including residential and community care.

The government recently consulted on two parts of this framework – a new single set of quality standards for all aged care services and a streamlined approach for assessing provider performance against them.

Professor Michael Fine

The proposed single set of standards and streamlined assessment will further progress aged care towards a more market-oriented system where quality will arguably be driven by greater consumer choice.

Given the critical role standards play in setting out core expectations for the safety and quality of care and services, it’s essential we examine the assumptions and the evidence underpinning the proposed changes.

Evidence of failings

Numerous inquiries, media reports and research studies have highlighted examples of failures of the current regulatory framework despite accreditation rates suggesting otherwise.

Issues have also been identified with a lack of direction within the standards on several key fronts including: minimum staffing ratios, indicators of nutritious food and the provision of health professionals including psychologists.

Clinical standards have also been criticised as lacking specific direction on critical issues including pain, medication management and oral health.

Recommendations to address these issues have included a more rigorous process of accreditation, with genuinely unannounced inspections, more robust collection of indicators of compliance and a more consistent approach among assessors.

The evidence from this research points to the merit of approaching aged care regulation through a new emphasis on outcomes rather than outputs, and underpinned by evidence-based research on effective and measurable clinical and quality of life outcomes.

Equally important, there is great value in reviewing various models for the collection, monitoring and regulation of these standards given the evidence of persistent failures with the current accreditation model.

Putting consumers at the centre

The government’s proposed changes to the standards and assessment framework seek to address three key competing agendas:

  • to address concerns on the shortcomings of the current regulatory system
  • to meet government deregulation and market reform programs, and
  • to achieve these two in a cost effective manner.

Dr Beatriz Cardona

In order to balance these, the government is seeking to reframe how we view quality and compliance in the context of a consumer-led, market system.

An approach to quality that places the older person at the centre of care is increasingly recognised as being fundamental.

Similar developments are taking place in other OECD countries with the aim of supporting the development of competition in the care market to enhance quality and contain costs.

However, there is no consensus yet on the instruments for assessment in this approach. This is because capturing “dignity” and “quality of life” as outcomes poses various challenges.

Research on measuring the impact of community care has highlighted the importance of standardised outcome measurement. There are various tools currently being tested in Australia to measure clinical and social care outcomes in residential and community care.

For instance, our recent pilot study uses the ACCOM tool to capture information on social care related quality of life (SCRQoL) along with data on the need for care and demographic and social aspects of community care users.

The draft standards and framework propose some guidelines on the type of indicators that can be used to determine if dignity, autonomy and choice have been met. Because they are not standardised however, making necessary comparisons and benchmarking to improve service delivery will be difficult.

Need for explicit standards

The proposed clinical standards represent challenges for assessment and monitoring given the approach in favour of more flexible, non-prescriptive language and purportedly, a more consumer-directed approach.

The balance between aged care being more responsive to consumer wishes and meeting standards for safe and effective care needs to be backed by expert clinical advice.

Evidence of high-prevalence risks among consumers must also be identified and addressed in the standards. These include oral health, dementia and cognitive decline, malnutrition, falls and fractures, pain, ulcers and depression.

Given these constitute basic building blocks of physiological needs and resident safety it’s essential that greater rather than lesser emphasis is needed on explicit and assessable standards for clinical care.

As evidence from other OECD countries indicates, the proposition that quality will be driven by consumers making choices and exercising control has not been demonstrated.

Consumer-driven quality hindered

While the research highlights numerous caveats surrounding a consumer-driven quality system, there is significant evidence indicating the positive value of consumer input in the planning, delivery and assessment of care outcomes.

There is also ample evidence that collecting and analysing clinical and social care data from aged care facility residents constitutes an essential step in the process of monitoring quality.

Just as we require basic safety standards be met for all new cars and for other significant purchases, it is clear that the market alone is not the solution to problems of quality and standards in aged care.

If we want to provide consumers of aged care with greater choice, a strong basic inspection and licensing system, backed with a robust complaints system, is essential.

Experience in both North America and Europe suggests that we need strongly policed agreed safety standards for all care services. Building on basic guarantees, mechanisms that enable providers to collect reliable outcome data and other indicators of quality can provide powerful means for ensuring ongoing improvements to quality.

Michael Fine is an honorary professor at Macquarie University and principal investigator on a study of the ACCOM. Dr Beatriz Cardona is a research fellow working on the ACCOM tool and a project officer with the The Multicultural Network.

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6 Responses to ‘The market alone is not the solution to problems of quality’

  1. Michael July 28, 2017 at 9:56 pm #

    Great to see academics studying the social dynamics in the sector doing research and bringing that research into the public debate to help us find a way out of the blind alley we have gone down.

    Professor Fine has spent years studying the nature of care and the type of system we need to make care that enhances lives and draws people together possible.

    Our aged care system needs real and reliable data to prevent it from drifting into fantasy. That is the first step forward. Professor Fine’s work in developing methods for collecting that data has enormous potential. He will need all our support to have that implemented in the current political climate.

    As the authors indicate “The market alone is not the solution to problems of quality”. It is clear that politicians alone are not going to contribute unless forced. We all need to engage and make sure that we get what is needed.

    The next step will be for for Australians from all walks of life becoming a caring community that engages with that data and uses it to to ensure that our vulnerable seniors get the sort of care and the quality of life from the market that we expect them to get.

  2. Sandra Hills July 28, 2017 at 10:10 pm #

    Many thanks Michael and Beatriz for your thoughtful insights . You are right on the money with your views

  3. Marcus Wigan July 29, 2017 at 7:59 pm #

    The feedback to the subjects of all this (us) need (1) to lay a real role and (2) have comprehensive information at several levels available to enable meaningful choice to be operative. I trust that these two items were left out of this project specification though oversight..if not please reconsider

  4. Liz July 31, 2017 at 12:27 pm #

    Thank you Michael; could not agree more. “The Market” is certainly not providing the solution at the moment and is a very simplistic notion. The system is broken.
    I do not see how the community and residential sectors can be put in the one category for quality standards; residents of aged care facilities are far more vulnerable in view of the fact that they require 24 hour care.
    “Consumer choice” is also a misnomer; the choices are very limited.

  5. Rex Graham July 31, 2017 at 1:06 pm #

    This article, which seeks to put markets and competition in their rightful place is very timely and apt. Governments continue to push a self-serving line that more competition and less regulation will deliver government services like aged care with greater quality at lower or contained cost. Sound too good to be true? That’s because it is.

    Of course there is a place for person-centred funding models, so that the service user has greater say over the services they will receive from competing service providers. But, as the article says, having this without clear client outcomes data by which to assess the quality of services being received, will not improve service delivery. Consumers need quality outcomes information so they can ‘purchase’ the best quality services.

    A weakness in the article is that it did not mention that collecting data on client outcomes is expensive. The last thing governments wants to hear is the need for more funding for data collection and analysis. But hear it they must. Governments can’t be allowed to get away with their relentless “markets solve everything” rhetoric.

  6. Windsor Gardener August 2, 2017 at 2:38 pm #

    I think the answers lie between using the learning from and the technology systems (read electronic records and portal) recently developed for the National Disability Insurance Scheme and the Dept of Health’s existing record keeping.

    Clients of the NDIS transition into the health system on reaching 65 years of age. Continuity of service is required so why not have just one system with the best of both cherry picked, that can be used for many purposes?

    While we can learn a lot from overseas, surely we have the current know how in the Australian environment with local operators, some of whom work in both the aged and disability sectors.

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