Customers or Citizens? Older People and Transition Care in

Australia Caroline Hayter PhD Candidate,

University of Sydney Faculty of Education and Social Work

Purpose

• Emergence of consumer rights – Economic perspectives – Human rights perspectives

• Enacting consumer rights –Choice mechanisms –Voice mechanisms

• Practice and Policy Implications • Further Research

Methodology

• Literature Review • Definition of transition care

“Transition care provides short term and active management for older people at the interface of acute/subacute, community care and residential aged care” (Department of Health and Ageing, 2011, pg 14) Goal oriented, time limited and therapy focused to optimise functioning of older people (Department of Health and Ageing, 2008: pg 14)

Why the rise of consumer in health and social care?

Personalisation • Disability rights movement in response to inflexible and rigid

services (Glendenning 2009) • Neo-liberal shifts in welfare states (Clarke et al 2007)

Policy and Practice • Putting people at the centre (Leadbetter, 2004) • Mechanisms

– Individualised budgets (Leadbetter, 2004) – Cash for care schemes – Restorative approaches

• Changes relationship between consumers and producers

Personalisation and Social Policy

Aged Care

• Economic Framework/ Human Rights Framework

• Aged Care Policy – Budget Holder

Model

– Goal focused

– Restorative models

Disability

• Human Rights Framework

• National Disability Insurance Scheme – Individualised

funding

– Self managed

Health

• Economic/Human Rights Framework

• Efficiency and Effectiveness

• Outcomes – Transition care

Citizens or Customers

Human Rights Perspective

• Consumer as citizens

• Empowerment

• Response to failures of welfare states in meeting individual needs

• Voice mechanisms via consumer directed models

(Moffatt et al, 2011, Clark, 2006),

Economic Perspective

• Consumer as customers or ‘choosers’

• Choice mechanisms part of modernisation of welfare

• Rational actors choosing and arranging care

• (Greener 2008, Powell et al 2009)

Clients/Patients or Differentiated Consumer

Professionalism

Client and Patient

• Professional guides the patient

• Whose voice?

• What choice?

• Balance between professional and consumers

Differentiated Consumer

• Diversity of consumers

• Resources, time, money and education

• Consumer as hedonist

• Consumer as activist

• Choice and voice mechanisms based on context (Simmons 2009)

Citizens, Clients or Customers or the Differentiated Consumer?

Citizen Political rights Participation

Collective

Human Rights

Customers Individuals

Market

Economic Rights

Client Professionalism Co-production

Voice mechanisms

Choice mechanisms

Policy Mechanisms

Policy Mechanisms

Citizen Political rights Participation

Collective

Customers Individuals

Market

Client Professionalism Co-production

Voice mechanisms • Complaints • Formal and

informal mechanisms

Choice mechanisms • Competition • Provider

choice • Exit

Choice and Voice

mechanisms

Older People and Choice

• Low take up of consumer directed care (individualised budgets and direct payments) in the UK for older people (Glendenning 2008, Moffat et al 2012)

• Relies on assumptions of agency – Some older people rely on others to exert rights and

agency (Goodin & Gibson, 1997)

• Older people want control, questions about mechanisms to promote choice (Moffat et al 2012)

Older People and Choice

• Lack of research on older people’s views and experiences of public services (Clarke and Newman: 2007)

• Differences between generations of older people views of being a consumer – Prospect of becoming a consumer can be daunting

(Baldock and Ungerson, 1994)

• Introduction of choice mechanisms can lead to inequity in outcomes (Barr, Fenton & Blane, 2008 & Hunter 2009)

Influence of Economic Ideas

• One dimensional economic view of ‘consumer as chooser’ (Powell et al 2009)

– Reflected in mechanisms for choice

• Are current policy directions in ageing and health policy in Australia focusing on the consumer as ‘chooser’?

– Implications for Transition Care Policy?

History of Transition Care in Australia

• Gap between acute care, community care and residential care for older people – Introduced in 2005

• Economic arguments – Health system benefits (Department of Health and Ageing,

2008) – Reductions in re-admissions to hospital (Department of

Health and Ageing, 2008)

• Human rights for older people – Improved functioning and well being of older people

(AIHW, 2012) – Flexibility and outcomes focused

0.0

50.0

100.0

150.0

200.0

250.0

300.0

350.0

2006/2007 2009/2010 2011/2012

Mill

ion

s

State &Territories

AustralianGovernment

Total Funding

Government Funding of Transition Care in Australia 2006/2007 – 2011/2012

Source: Productivity Commission Table 13A.5 (2013), (2009), (2008) Table 13A.69

0

10

20

30

40

50

0-64 65-74 75-84 85 plus

Perc

enta

ge

Age

Transition Care Episodes by Age of Recipients at Admission 2010-11

Source: AIHW (2012: pg 20)

Personalisation and Impact on Transition Care

Practice

• Short term, goal oriented and outcome focused

• Early intervention via therapy

• Focus on physical functioning of older people rather than social and emotional wellbeing?

Policy

• Growth in funding and availability of places

• Budget holder model – Shift to individualised

budgets?

– Self managed

• Voice mechanisms

• Choice mechanisms

Choice, Competition and Exit

• Choice and competition create efficient and effective service systems (Le Grand, 2007)

• Six dimensions of choice – Provider (Where?) – Professional (Who?) – Service (What?) – Choice of appointment (When?) – Choice of access channel (How?) – Choice of additional services

• Capacity for exit

Older People as Citizens

• Expression of choice through voice mechanisms

– Formal and informal voice

– Engagement of older people

– Complaints processes

– Education of older people about their rights

– Service user lead rather than system driven

Choice plus Voice Mechanisms

• What works when, where, why and in what ways?

• Voice mechanisms

– Specific contexts

– Vulnerability of service users

• Choice mechanisms

– Where, Who, What, When, How?

Practice Implications

• Working with Older People

– How professionals view older people?

– Goals

• Professionals or the person’s goals?

– Outcomes

• Outcomes for whom, older people or the system?

– Choice

• Provider, professional?

• Older people and relationships

Practice Implications

• Co - Production Approach – Older people and professionals work to co-

produce outcomes

– Access to information and knowledge

– Power differentials between services and older people who use services (Ottman, 2009, 2011) • Does this downplay inequalities between older people

and professionals?

• Challenge the role of professionals and empowering older people

Policy Implications

• Context matters – Danger in having a narrow conception of choice can

lead to assumptions of ‘users’ as choosers (Simmons & Powell, 2009)

– Acknowledge a diverse conception of the consumer

– What kinds of voice and choice are required?

– Do the different types of the consumer have any resonance in different areas?

• Outcomes – Equity of access

Policy Implications

• Outcomes

– Regulatory framework in aged care still focused on process rather than outcomes for older people

• What is an outcome for the health system?

• What is an outcome for older people ?

• Research

– Older people and relationship with public services

– What voice and choice mechanisms work in different contexts?

Conclusion

References

Australian Institute of Health and Welfare. (2012). Older people leaving hospital: A statistical overview of the Transition Care Program 2009–10 and 2010–11. Canberra: Australian Institute of Health and Welfare,.

Baldock, J., & Ungerson, C. (1994). Becoming Consumers of Community Care; Households Within the Mixed Economy of Welfare, Community Care into Practice Services (pp. 1-56). York Joseph Rowntree Foundation

Barr, D., A,, Fenton, L., & Blane, D. (2008). The Claim for Patient Choice and Equity Journal of Medical Ethics, 34, 271-274.

Clarke, J. (2006). Consumers, Clients or Citizens? Politics, Policy and Practice in the Reform of Social Care. European Societies, 8(3), 423-422.

Clark, J., Newman, C., Smith, N., Vidler, E., & Westmarland, L. (2007). Public Service Reform: the Rise of the Citizen- Consumer Creating Citizen Consumers Changing Publics and Changing Public Services (pp. 27-46).

Department of Health and Ageing. (2011). Transition Care Program Guidelines Canberra Australian Government.

Department of Health and Ageing. (2008). National Evaluation of the Transition Care

Program. Canberra Australian Government

References

Hirschman, A. (Ed.). (1970). Exit, Voice and Loyalty Responses to the Decline in Firms, Organisations and States Cambridge Massachusetts: Harvard University Press Hunter, D., J,. (2009). The case against competition. Health Economics, Policy and Law 4, 489-501. Goodin, D., & Gibson, D. (1997). Rights Young and Old. Oxford Journal of Legal Studies 17(2). Glendinning, C. (2009). The Consumer in Social Care In R. Simmons, Powell, M., & Greener, I., (Ed.), The Consumer in Public Services, Choice, Values and Difference Bristol The Policy Press Greener, I. (2008). Choice and Voice – A Review. Social Policy and Society, 7(02), 255-265.

Le Grand, J. (2007). The Other Invisible Hand Delivering Public Services through Choice and Competition. New Jersey: Princeton University Press. Leadbeater, C. (2004). Personalisation through Participation A New Script for Public Services United Kingdom: Demos. Moffat, S., Higgs, P., Rummery, K., & Ree Jones, I. (2012). Choice Consumerism and Devolution: Growing Old in the Welfare States of Scotland, Wales and England Ageing and Society, 32(5), 1-22.

References Ottmann, G., Laragy, C., Allen, J., & Feldman, P. (2011). Coproduction in Practice: Participatory Action Research to Develop a Model of Community Aged Care. Systemic Practice and Action Research, 24(5), 413-427. Ottmann, G., Laragy, C., & Haddon, M. (2009). Experiences of disability consumer-directed care users in Australia: results from a longitudinal qualitative study. Health and Social Care in the Community 17(5), 466-475. Productivity Commission. (2013). Report on Government Services Aged Care Canberra: Productivity Commission Productivity Commission. (2009/10). Aged Care Services In Productivity Commission (Ed.), Report on Government Services (pp. 13.11-13.80). Canberra: Productivity Commission Productivity Commission. (2008). Report on Government Services - Aged Care Services Canberra: Productivity Commission Simmons, R., & Powell, M. (2009). Conclusion: the Consumer in Public Services. In R. Simmons, M. Powell & I. Greener (Eds.), The Consumer in Public Services - Choice, Values and Difference UK: The Policy Press

Contact Details

Caroline Hayter

University of Sydney

carriehayter@gmail.com

Twitter @carriehayter

Linkedin http://au.linkedin.com/pub/carrie-hayter/34/536/517/