Medicare, the government voucher system for out of hospital medical services, is now 36 years old. It has enjoyed widespread support over that time and, while opposed by the medical profession initially, and certain politicians since, albeit not publicly, it has become accepted by health professionals and the general public. For many Australians it is the only system they have ever experienced.

Medicare is similar to other national health schemes found in the developed world and while most agree it is not perfect they are glad it is not what we see in the USA.

This model of government financing the medical sector has in recent years been extended to aged care services, disability care, and mental health support. The government offers packages of care in a competitive market for contractors to supply the designated services to clients.

Contracts are awarded to large organisations that are incentivised to employ staff with minimum qualifications for fixed periods of time. The focus is on doing the minimum required in the shortest period of time to meet the requirements of the contract. Fast and cheap! (See Good, Fast, Cheap - Pick Any Two)

Since the contracts are usually specified for a short period of time there is no long -term security for the organisation or the staff. For those on the bottom ranks of the organisation the lack of security in these arrangements is quite stressful. Those at the top have more options to use their skills to find employment in other areas. However, in both cases, there is no long term commitment to the organisation or its activities.

“Commissioning creates its own series of problems… any solution will recognise the value derived from a skilled workforce efficiently caring for their charges” - The King’s Fund

Late last year the Royal Commission into Aged Care Quality and Safety released its interim report. Its title, Neglect, summed things up. The issues for patients and their families in negotiating the My Aged Care system’s enrolment process, access issues and quality of care are well known to GPs.

The constraints placed on Aged Care staff were examined in detail by the Commission, which noted in its introduction:-

“We have heard about an aged care workforce under pressure. Intense, task-driven regimes govern the lives of both those receiving care and those delivering it. While there are exceptions, most nurses, carer workers and allied health practitioners delivering care are doing their best in extremely trying circumstances where there are constraints on their time and on the resources available to them. This has been vividly described by the former and current aged care staff who have given evidence.

“The aged care sector suffers from severe difficulties in recruiting and retaining staff. Workloads are heavy. Pay and conditions are poor, signalling that working in aged care is not a valued occupation. Innovation is stymied. Education and training are patchy and there is no defined career path for staff. Leadership is lacking. Major change is necessary to deliver the certainty and working environment that staff need to deliver great quality care.”

The government’s preferred model of market forces maximising the outcomes also came under criticism by the Commission. The lack of data about current practices and performance turns selecting a provider into a lottery.”

The report concluded that,

“The structure of the current system has been framed around the idea of a ‘market’ for aged care services where older people are described as ‘clients’ or ‘customers’ who are able to choose between competitively marketed services. But many older people are not in a position to meaningfully negotiate prices, services or care standards with aged care providers. The notion that most care is ‘consumer-directed’ is just not true. Despite appearances, despite rhetoric, there is little choice with aged care. It is a myth that aged care is an effective consumer-driven market.”

Late last year the Productivity Commission’s Draft Report into Mental Health was also released. Although somewhat less critical than the Aged Care Commission of current arrangements, it too highlighted the uncertainty relating to short term contracts and recommended that the minimum contract length be increased to five years.

This recommendation was echoed by the NSW Mental Health Coordinating Council Workforce Survey (2019) that found nearly half of all community mental health workers were on short term contracts or were casual employees. The survey recommended further analysis of the industry with particular attention being directed to the effectiveness and training of the workers.

Such issues are not unique to Australia. The UK’s National Health has long championed the commissioning of health services and general practice care and has often served as a model for such approaches in other countries. The commissioning framework undergoes constant change with various programs designed to improve care.

The King’s Fund, an independent organisation that monitors health care in England, recently reviewed the difficulties Primary Care Networks face in caring for their elderly at home and found that the greatest challenges were in maintaining a skilled workforce. They stated:-

“Community services have seen some of the sharpest reductions in staff numbers in recent years, including among community nurses. Put simply, these standards cannot be achieved without the staff to deliver them.”

Governments around the world are under increasing pressure to provide services for their aging and infirm populations. Commissioning is a vastly more efficient method of addressing these issues than the government running the services directly themselves. Nevertheless commissioning creates its own series of problems that need addressing and any solution will recognise the value derived from a skilled workforce efficiently caring for their charges.

Humans are complicated and caring for them requires a range of skills. Solutions to look after them will need to move past the “paperclip” approach.