Consumer Directed Care – More Choice or Voice for Older People?

Carrie HayterPhD Candidate

Faculty of Education and Social WorkUniversity of Sydney

Big Ideas on AgeingACH Group

Sir Keith Wilson OrationSouth Australian Gerontology Conference

October 2013

Purpose

• Why consumer directed care?– Different ideological perspectives – Policy landscape in Australia – Assumptions of consumer directed care

• What are the proposed benefits of consumer directed care?– Choice and control – Flexibility and innovation– Hearing the ‘voice’ of older people

Purpose

• What are the risks of consumer directed care?– Assumptions and mechanisms for choice – Assumptions and mechanisms for voice

• Implications– Policy– Research – Practice

Methodology

• Literature review – PhD research

• Historical perspective – Lessons from reflecting on the history of aged

care policy in Australia• Reflecting on policy and practice

What is Consumer Directed Care?

• Mechanisms to implement more personalised or ‘self directed care’ (Cortis, Meagher, Chan, Davidson & Fattore, 2013)

• Person centred care a form of Consumer Directed Care?

• Primary mechanisms– Individualised budgets – Cash for Care

8 April 2023

Case Management &

Brokerage

Individualised Budgets

(Budget Holder Model)

Consumer Directed Care 6

Cash for Care(Carers

payment)

Consumer Directed Care in Aged Care Australia

1980s 2011/2012

Consumer Directed Care in Australia

Disability policy • Movement towards

individualised funding through self managed packages – Victoria– Western Australia– National Disability Insurance

Scheme (NDIS)• Features

– Employing own staff

Aged Care Policy • Consumer Directed Care as

an individualised budget model

• Features– Budget holder model– Older people and provider

‘co-produce’ outcomes

Assumptions of Consumer Directed Care

• More ‘consumer’ choice and control will:– Overcome welfare paternalism;– Improve efficiency and effectiveness;– Promote the well being and independence of

people with disabilities and older people;– People will be active participants in their care

(Glendinning, 2008, Cortis et al, 2013)• Assumption that ‘choice’ will give people more

‘voice’

The rise of the ‘consumer’

Economic perspectives • Influence of neo-liberalism• Older people as a

‘consumer’ or purchaser within the marketplace

• Exercising economic power within the marketplace

• ‘Consumers’ and producers (Clarke et al, 2007)

• Focus on choice

Human rights perspectives • Rise and influence of social

movements (eg disability rights movements, mental health service user movement) (Barnes, 2009, Beresford, 2009, Glendinning, 2009)

• Rigidity and inflexibility of public services

• Service users as ‘citizens’• Focuses on voice

The rise of the ‘consumer’

Challenges the ‘professional ‘• Older people seen as ‘clients’• Based on trust and reciprocity

between the ‘client’ and the ‘professional’

• Criticisms that clients were passive recipients of care

• Professionals are self interested and provide limited choice.

Foucaultian notion of ‘governmentality’

• Questions whether service users are active or passive subjects (Harrison, 2012)

• Explores how the language of ‘consumerism’ becomes embedded in policy discourse

What does having choice mean?

Choice and Stakeholders

Older people

Carers of older people

Organisations supporting older

people

Efficiency & effectiveness

Respect

Having a break

Choice of staff, voice of older

people

Federal Government

Choice – A Political Concept? Consumer as

Purchaser

Market mechanisms to enact ‘consumer’ choice (eg individualised budgets and

direct payments)

Choice and competition (LeGrand, 2007)

Citizen

Role of State

Mechanisms to promote service user voice

(Beresford, 2009, Barnes, 2009)

Social and political rights

Economic purchasing power

Risks of Consumer Directed Care

• Service Users– Access to economic

resources can effect ability to act as a ‘consumer’ (Glendinning, 2008, Le Grand, 2007)

– Older people may not be prepared to act as ‘consumers’ (Moffatt et al 2011)

• Service Users• Low take up of

individualised budgets of older people (Glendinning et al 2008, Moran et al, 2013)

• Mixed evidence about the benefits for older people.

• Privatisation of care (Glendinning, 2012)

Risks of Consumer Directed Care

• Workforce– Move towards

contracting– Service continuity and

job security – Income security – Quality and skills of

workforce (Cortis et al, 2013)

• Providers – Market may not respond

to the interests of service users (Glendinning, 2008)

– Appropriate supply of providers and types of services

– Administrative costs of administering individualised budgets (Cortis et al, 2013, Wilberforce et al, 2011)

Risks of Consumer Directed Care

• Government– Access and equity– Reduces cross

subsidisation of funding a feature of block funding

– Funding may not meet all needs (Moran et al, 2013)

• Other – Risks commodifying and

privatising social and collective responsibilities for care (Glendinning, 2009, pg 190)

Australia’s Aged Care System • Mixed economy of care • Hybrid system where informal supported by the formal

Managed Market – Hybrid and Competitive Tendering and Contracting (Davidson,

2011/12)• Limited choice and control for older people (Productivity

Commission, 2011)• Power is vested in the provider • Consumer Directed Care - Packaged Care

– Individualised budget holder model

Voice rather than choice?

“I am here to listen but not ask questions”

What does having a ‘voice’ mean?• Voice

– Having more say in services

– Individual or collective voice (Simmons et al, 2011)

– Voice can go beyond the confines of choice• Relationships• Connections (Simmons et

al, 2011)– Exit (Hirschman, 1970)

• Voice mechanisms – Complaints– Surveys– Political activity through

voting or lobbying– Participation in

representative bodies or groups (Simmons et al, 2011)

The political spectrum of voice Liberty -

Liberal prioritising of rights

minimum state interference State fulfils basic needs

Source: Greener, 2008

Right wing Left wing

Liberty based on prioritising of need

Increased reliance on self help

Individual

‘Active citizens’

Collective Interests

Can voice mechanisms increase choice?

Neo-liberal economic • Voice mechanisms (such as

complaints, and service user forums) alone wont encourage providers to innovate (Le Grand, 2007)

• Voice mechanisms need to be coupled with competition. (Le Grand, 2007)

Human rights perspectives • Creating structures to hear and

encourage the collective and organised voice of service users can change service systems (Beresford, 2009, Barnes, 2009).

• Acknowledge power differences between users and providers (Barnes 2009, Beresford)

• Voice as exit (Hirschman, 1970) can promote choice

Voice mechanisms and Aged Care in Australia

• Aged care system dominated by interests of professionals, providers and government (Sax, 1990, Gibson, 1998)– Older people seen but not heard

• Emergence of voice mechanisms in the late 1980s early 1990s– User rights strategies through National Standards– Limited awareness and impact on older people (Gibson, 1998,

House of Representatives Standing Committee on Community Affairs, 1994)

– Consultative structures for older people in policy processes (Howe, 1992)

– Impact on policy outcomes and changes?

Voice mechanisms and Aged Care in Australia

• Organised voice of older people through consumer groups– Growing awareness of the ‘voice’ of older people– Will this translate into changes in practice? • Challenging staff attitudes to ageing• Structures to hear the voices of older people (Barnes &

Bennett, 1998)• Appropriate structures for different groups of older

people

Risks of voice mechanisms and Consumer Directed Care

• Voice alone wont change behaviour of providers (Le Grand, 2007)– Aged care in Australia

• Providers may not ‘hear’ the voices of older people– Ignores power differences between older people

and providers (Ottmann et al, 2011).• ‘Organised voice’ of older people – Interests they represent

Benefits of voice mechanisms and Consumer Directed Care

• Citizenship – Individual and collective mechanisms (Simmons et al,

2011)– Vehicle for politicising older people

• Opportunity for engagement– Explore depth of feeling (Simmons et al, 2011)– Collective or group response (Barnes & Bennett, 1998)

• Partnerships – Older people and providers co-produce outcomes

Policy Implications of Choice and Voice

• Risk of ‘one model’ of consumer directed care– Will individualised budgets cater to the diversity of

older people?• Mixed evidence of benefits of individualised budgets for

older people in the UK (Moran et al, 2013)• Resources and support

– How are providers supported to manage and adapt to changes?

• Diversity of policy responses to respond to the diversity of older people

Policy Implications of Choice and Voice

• Older people– Engaged and politically active – How to engage people who are vulnerable

because of physical health and or cognitive issues?– Challenge stereotypes of ageism – Provide appropriate political structures to ensure

the voices or organised voices of older people are heard

Further Research

• Research on the perspectives of older people – How different cohorts of older people respond to

individualised budgets– Expectations of different cohorts of older people– Older people from Culturally and Linguistically

Diverse (CALD) backgrounds and Aboriginal and Torres Strait Islander people

Further Research

• Research on workers experience of consumer directed models– Limited research on the experiences of support

workers in consumer directed models

Conclusion

• Choice is not the only fruit• Voice can be a mechanism for more ‘choice’• Whose interests are we trading off in the

interests of choice as part of Consumer Directed Care?– Trade off conditions of workers will this have a

direct impact on quality of care?– Preparing and supporting older people– Engaging and supporting carers

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Contact Details

Carrie HayterEmail: carriehayter@gmail.com

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

Twitter @carriehayter