This is a story about a policy issue that’s not exactly high-profile or glamorous, but which helps explain why we’re going to struggle for a long time to get a better aged care system. It’s about physiotherapy in aged care.
Physiotherapists play a crucial role in relieving pain and in improving mobility for the elderly. Potentially they’re also an important source of savings for aged care providers — more of that later.
In August, the Australian Physiotherapy Association (APA) began talking about the loss of significant numbers of physios from the aged care sector. APA president Scott Willis told a Senate committee hearing into the government’s aged care bill that providers were letting about 50% of their physios go.
Why? That’s a complicated story — and that complexity is what makes improving aged care so hard.
Until recently, providers were funded for four sessions of 20 minutes of physio a week. But the physio was limited to pain management. The problem with that is obvious: mobility is fundamental to quality of life, and helping residents regain mobility not merely improves quality of life — it also reduces the risks of falls and potentially reduces costs for providers by enabling residents to perform basic self-care tasks they would otherwise need staff assistance with.
But the aged care royal commission found many providers weren’t prioritising mobility. It recommended providers be required to retain at least one physio and one of each of a range of other allied health professionals: such as speech therapists, oral health practitioners and occupational therapists.
Meanwhile the new funding model for aged care, Australian National Aged Care Classification (AN-ACC), was being developed. Mobility is central to its framework, along with cognitive ability and mental health. The previous government decided that physio would no longer be separately funded — and then minister Richard Colbeck bizarrely attacked physiotherapists for “over-servicing” aged care residents. Challenged by the APA to provide evidence of over-servicing, Colbeck didn’t respond.
Labor under Aged Care Minister Anika Wells is retaining the approach of not directly funding physio in what will be greater funding for providers under AN-ACC. There will be no mandated level of physio at all, nor for other allied health services.
Which is why providers are dumping physios. Like I said, it’s complicated.
AN-ACC has an inbuilt incentive to use physios. It incorporates recommendation 121 of the aged care royal commission: “A resident should not be required to be reassessed for funding eligibility if their condition improves under the care of a provider.” How’s that an incentive? Because if a provider invests in physio that improves a resident’s mobility, meaning they have less need for staffing assistance, they will continue to receive the same category of payment as for the original assessment. Same funding but lower costs.
The APA warns that providers are using this greater discretion over service provision to replace accredited allied health professionals with less- or lower-accredited “lifestyle officers” who will adopt a tick-a-box approach to therapies such as mobility. Plainly the APA is self-interested on the issue, but it also knows what’s been happening on the ground.
The government funding approach makes financial sense — and is in line with the tradition of neoliberal public service thinking in which it’s better to specify the outcomes wanted than to mandate how they are to be achieved, giving flexibility for innovation and efficiency.
But this is a sector where too much flexibility and too little mandating has taken place, judging by the consistently poor state of aged care. Providers may recognise the benefits of getting residents more mobile, but see it as a lower priority than saving money by employing less-accredited staff to achieve it. Good policy, in other words, may have poor outcomes.
The government says it has been collecting much more detailed data on spending by aged care providers, including what kind of staff providers employ. This, it says, will provide greater visibility if this is what transpires. Clearly, APA says, it’s happening already.
And just to further complicate matters, no one is really sure of the state of the broader allied health workforce. Because allied health is so important for both aged care and the NDIS — and demand will grow as those sectors expand, along with the expansion of the health sector — the Health Department has begun looking at what exactly we know about the workforce. The answer: too little. There are big gaps in the data available, and “allied health” covers a range of occupations, some of which have good workforce data, and others that are essentially self-regulated.
To even know what we have and what we’ll need in terms of workforce, the government wants a national minimum data set across allied health to inform planning.
We are still at the “know what we don’t know” stage for a crucial sector.
This is an issue of fundamental importance to hundreds of thousands of Australian seniors both in residential care and receiving home care, as well as for NDIS recipients — and for the providers of those services. Beyond that it attracts little attention. But it illustrates how fraught policymaking can be even when there’s goodwill on all sides.
