South Island Health Managers Seminar
Hon Lianne Dalziel Speech Notes
Managers from the private sector providing care for the older person
Good morning and thank you for the invitation to speak to you today. Yvonne Syme-Boulton has asked me to speak to you today on relevant issues regarding health care of the elderly.
In order to put my comments in context, I thought I should begin by explaining my role as Minister for Senior Citizens. The Senior Citizens portfolio is both a population portfolio, in that I am focussed on the issues that are of concern to older New Zealanders, and it is an advocacy portfolio, in terms of identifying issues that are relevant to older people during the policy development process. I have a small policy unit within the Ministry of Social Policy (soon to be the Ministry for Social Development), called the Senior Citizens Unit, and I have a small Senior Citizens Advisory Council. Between them they provide me with advice to support my advocacy and broader oversight roles.
I do not hold the budget for any of the functional arms of government that relate specifically to older New Zealanders. It is my role to seek to influence the Ministers who do. In terms of the Health of Older People, I talk to Ruth Dyson; general health issues, Annette King; Older Persons' Driver licensing, Mark Gosche; superannuation, Michael Cullen & Steve Maharey.
Prior to the election, I was the opposition spokesperson on Youth Affairs, but it didn't take me long to realise that the issues I had been looking at in terms of the younger generation were very similar to those that were important for the older generation. It was all about that all-important sense of belonging, and desire to participate. Younger people who don't have that can become alienated and troubled, and older people can end up feeling isolated and afraid.
This is in part what motivated my desire to deliver a Positive Ageing Strategy for New Zealand. That strategy was launched in April and it is now in the process of being reported back to the regions, which will enable partnerships to develop between central government, local government & community groups, making the Strategy meaningful in a local sense. The purpose of the Strategy is to provide a framework that encourages the development of communities for all ages.
The reason that I mention this to you, is that it provides an ideal framework for formulating representations to government. I told a conference last weekend to contextualise their remits within the Positive Ageing Framework. The Strategy contains a number of objectives and actions that are very relevant to your sector, and I simply leave with you the idea that this is an approach that could be adopted.
Last month, Social Services Minister Steve Maharey and I launched a research report on the Living Standards of Older New Zealanders that was produced by the Ministry of Social Policy.
Although it told us the majority of older New Zealanders were doing okay, it told us for the first time what contributed to those who were not doing so well - divorce/separation; death of a spouse; significant period of illness; major hospital operation; low paid jobs; intermittent work; redundancy; lack of additional income over superannuation; rental accommodation rather than home ownership.
This says we have enormous challenges for a generation which didn't experience a job for life, one spouse, one house and the "save first, buy later" ethic.
It may be true that my generation of retirees will be healthier and better educated than the one that precedes us, but it also true that we will live longer. This does raise serious questions about how to fund health in the future. I know Annette King has said publicly recently that we need to start thinking about whether we have a form of dedicated tax or social insurance. I believe we must have this debate, and it should be an open and honest one.
Although, the cost of residential care cannot be isolated from the range of home support and other health services for older New Zealanders, it is true that it represents a disproportionate share of the total DSS Budget. This is in part a direct consequence of including a demand driven service within a ring-fenced Budget. The squeeze has been on since the residential care subsidy was transferred from Vote: Social Welfare to the Disability Support Services component of Vote: Health. However, it is a fact that only five percent of the 65+ age group live in residential care settings - with this increasing to 25 % for those over 85 years of age. And although it would be fair to say that the levels of frailty and dependency among residential care residents have increased exponentially over the past 20 years, the fact is that the cost of residential care is approximately 40% of the total DSS Budget. This is an issue we have to face up to.
The first step was the decision to remove Older Persons Health from the DSS ring-fence. Ruth Dyson announced the decision to separate off the funding for disability support services for the 65+ age group late last month. I have often made the point that the inclusion of older persons health in the DSS ring-fence ignored the fact that many older people's disabilities arise from their health needs.
The next step is the Older Persons' Health Strategy, which will be released in draft form for consultation shortly.
When Ruth announced the separation of funding decision, I set out the following key components of an older persons' health strategy:
· a comprehensive assessment, treatment and rehabilitation service · better access to elective surgery when needed · a commitment to integration of services, particularly between institutional care and the community
That is essentially the vision of the Positive Ageing Strategy.
Without giving away any details of the Older Persons' Health Strategy, you will have seen in my speeches and also in comments from Ruth Dyson, that we favour a model that represents an integrated continuum of care for older people.
I have commented favourably in the past on the Elder Care Canterbury Project and how it is an excellent example of co-ordination and support for older people.
That level of co-ordination was one of the issues highlighted in the 10th National Health Committee report on the health care of older people. The report specifically recommended that future health care services needed to achieve integrated service delivery, as well as a coherent continuum of care and support to older people and their carers.
In order to prepare for the submissions that you will want to make on the Older Persons Health Strategy, I suggest you look at the NHC Report, as well as the Positive Ageing Strategy's health Goal: Health Goal: Equitable, timely, affordable and accessible health services for older people Actions: · Promotion of holistic-based wellness throughout the life-cycle · Develop health service options that allow integrated planning, funding and delivery of primary, secondary, residential care and community support services · Ensure the availability of multi-disciplinary, comprehensive geriatric needs assessment throughout New Zealand. Extract Positive Ageing Strategy 2001
Another one of the Goals is that older people feel safe and secure and can 'age in place'.
Given that the vast majority of older New Zealanders do not enter residential care, and given that successful primary health strategies could reduce the percentages over time, it makes sense for those involved in residential care provision to think about where you sit in the continuum of care, and whether there is a role for you in terms of 'ageing in place'. That may sound contradictory, but it is not.
When you think of the continuum, there will be different stages in an older persons' health care needs. What about the period following an acute admission to hospital? A transfer to the ATR unit, may result in a 'step-down' option being assessed as a more appropriate level of support than a secondary or tertiary hospital setting, and may assist in the strengthening required for return to home. Surely a residential care facility could offer this service.
There are also roles that residential care facilities can and do play in respite care for timeout for the carers, and in the rehabilitation of individuals.
I was watching Holmes a couple of weeks ago, and saw one older person, who had been placed under the observation at the GP run Bealey Avenue Emergency after-hours service. And they showed another person, who had been placed in a rest-home for a few days, so his condition could be stabilised, before going back home.
In both instances I could see significantly lower cost, with no compromise in quality or safety. And it is this lack of compromise on quality and safety that must be the prerequisite for health service delivery changes.
I really do recommend that you take a broad perspective in formulating your submission on the Strategy.
Residential Care Subsidy
Onto the Residential Care Subsidy. You will appreciate that as this matter is currently under consideration by government, I am not able to address this issue directly.
I am certainly aware of concerns within the residential care sector that the subsidy has not increased for three or four years, which of course is not unique to those who provide residential care to older people. The bottom line is that the previous government hid the extent of the problem through the ever-increasing annual deficit in DSS funding.
However, that is not to say that this government is not committed to resolving the funding issues, and I know Ruth Dyson has been working extremely hard on finding that resolution.
The other issue around the Residential Care Subsidy, is the government's planned removal of the asset test. We have committed to introduce legislation effecting its removal in this term in office, however, the timetable is still undecided for implementation. When you consider that the estimated cost of removing the asset test is somewhere around $200 million-$250 million, and you know that this sum has to come from somewhere, then affordability has to be a strong determining factor. In my role as an advocacy Minister I have promoted a gradual phase-out of the asset test.
I don't support the asset test for one reason, and that is the potential for elder abuse that it represents. I want decisions made on the health needs of the individual, not the financial concerns of the family. The Law Commission's report on the Misuse of Enduring Powers of Attorney cited such a case as an example of elder abuse.
Health and Disability Services (Safety) Bill
Many of you will be following the Health and Disability and Services (Safety) Bill which specifically seeks to improve the processes for auditing and accrediting residential care facilities. The Bill is currently awaiting its third reading.
Under the provisions of the Bill, new accrediting processes will be established and national Health & Disability sector standards introduced. The following standards have already been prepared by Standards NZ: · Sector standards for all facilities · Audit tools for hospitals and residential care · Infection control standards · Restraint minimisation & Safe practice standards · Revised mental health standards The Minister of Health will sign these standards once the Bill is passed, and there may be others developed over time.
A key feature of the changes to the Bill is the designation of the Director-General of Health as the sole certifier of health providers. That will not be devolved to audit agencies - theirs will be a reporting function; the decision will rest with the D-G of Health. The Ministry of Health will also have the power to undertake spot audits of providers to test the auditing process and to investigate concerns they may have. The D-G has also been given power in the Bill to set specific conditions for certification.
In response to concerns about the lack of specification about levels of nursing in the generic standards, work is under-way on designing D-G conditions for nursing levels in aged care facilities. Key stakeholders are involved in a consultation advisory group.
Although the legislative timetable is reasonably full, the Bill is relatively high on the Order Paper, and is ready to go, once the supplementary work is completed.
I feel very strongly about this area, and it's one that I receive many calls about. Despite the Health & Disability Code of Consumer Rights, many people feel frightened about complaining because they have to leave their mother, father, husband or wife behind, and they tell me that they are fearful that some form of retaliatory action will be taken. That's not good for the individual, nor is it good for the sector. There is a lot of trust that needs to be re-established in the light of recent publicity, but I am telling you that there is more concern out there than is evidenced by publicity.
A particular level of concern is expressed by those whose relatives cannot speak for themselves. Many of these difficulties relate to the care of people with dementia. In response to these concerns, Ruth Dyson announced a working group would be set up to look at how these services could be improved. She also said that stricter service specifications relating to staffing levels and training were ready to be introduced.
Although I am an advocacy Minister, this year I have been given special responsibility for one piece of legislation this year and that is the retirement villages legislation. This is relevant to you because most retirement villages have residential care facilities attached to them.
The concerns that have been raised with me relate to older people who take up residence in a retirement village unit, and are then, often caught up in complex legal matters and contracts, which can in fact defeat the whole purpose of moving into the village in the first place.
Most people are looking for security, companionship, independence and support when needed. The idea of a continuum of care is very attractive to many older people. With a rest home on site, they don't even have to move.
However, the real problem is that people do not understand what they have bought into. The message I am taking around New Zealand is that investing in a retirement village does not equate to purchasing property you can sell. If people understand that, then explaining the consequences, in advance, in plain English, will help. An effective complaints' mechanism will also be a feature of the legislation, as it is important to recognise that these are peoples' 'homes', even though they don't 'own' them in the traditional sense.
Well that's enough from me. I have seen your agenda, and I am impressed at the depth and range of issues that you will be traversing in this seminar. I am a strong supporter of ongoing professional development, and consider it as critical at the level of health management as it is at the health professional level.
I am glad I have had the opportunity to traverse the range of issues relating to the health of older New Zealanders from the perspective of Minister for Senior Citizens, and I would be happy to answer any questions you may have.