Australia's aged care crisis escalates - staff shortage doubles
Author: Jarrod Ball, CEDA Chief Economist
The COVID-19 pandemic has necessitated rapid and fundamental shifts in how human services are delivered in Australia. The expansion of telehealth demonstrated that technology is readily available to deliver greater convenience and access to services for the community – where the will to change exists. A survey commissioned by NBN Co. found that almost half of Australians who visited their GP in the early phase of the pandemic did so virtually via telehealth services, and almost two thirds of respondents said they would continue using telehealth services into the future.
Governments have no choice now but to use the COVID-19 moment to drive permanent changes to embed technology and data into human services. The critical imperative for governments is that those services meet community expectations of quality and that there is trust in the technology and data underpinning those services. Timely and convenient access to human services will also be critical in a recession that will entrench and exacerbate existing disadvantage and vulnerability for many in the community.
The starting point must be more convenient and easier to access human services for all in the community, complementing and enhancing the ‘human touch’ rather than replacing it. The broader benefits will only be felt if the service meets community expectations. A relentless focus on fiscal savings or ensuring regulatory compliance often sees government digitisation efforts fail, building community scepticism and distrust.
Each contribution to this report outlines how digitisation can provide the community with better human services in the most convenient setting at the right time. But there are broader enablers required to make this happen.
The first is data. Providing better human services requires more sophisticated collection, storage, sharing and application of data. Governments are taking important steps to facilitate this, including through the Commonwealth Government’s forthcoming Data Availability and Transparency legislation. Incorporating more data in human services needs to meaningfully enhance these services, and the data needs to be collected, stored and applied in a transparent way to ensure community trust. Recent experiences demonstrate the value of data in a crisis – whether this is emergency responses to bushfires or contact tracing for COVID-19. But data cannot simply be switched on in a crisis – it must be part of business as usual for government service delivery.
Secondly, digital inclusion remains problematic for Australia. It is not safe to assume everyone in the community has the same access to digital technology. At the start of the pandemic, research showed that 2.5 million Australians were not connected to the internet. A lack of digital literacy also means that even where there is the means to connect, not everyone will have the same ability to use hardware and applications to interact with the required services. Financial and technical support must be integrated into our policy settings.
Third, we need better knowledge sharing and coordination across jurisdictions and sectors of human services. Despite renewed cooperation and coordination between levels of government as a result of COVID-19, it is apparent that many governments are continuing to digitise their human services without leveraging the knowledge and experience of other governments that are further ahead in this process. Doing this could enable better services and avoid mistakes that prove costly for taxpayers.
Finally, we need to invest in and grow the human services sector. Human services are often seen as a cost or drain on the economy despite the value that the community places on them, as evident in the results of CEDA’s 2018 Community Pulse survey, which found government delivery of critical services and support in health and aged care were among the top priorities for Australians. They also deliver well-established long-term economic benefits to participation and productivity. But the economic importance of human services is also right in front of our eyes. Healthcare and social assistance employs around 1.8 million people, accounting for 14 per cent of the workforce. As Professor Elizabeth Hill recently demonstrated in CEDA’s Labour market policy after COVID-19, human services can also play an important role in Australia’s jobs recovery.
The five human services explored here accounted for more than $150 billion of government expenditure last year. This expenditure should be seen as an investment in building the capacity of governments, the private sector, not-for-profits, cooperatives and mutuals to deliver human services that are constantly improving and delivering the best value for the community.
Dr Rob Grenfell (CSIRO) begins our expert contributions with a short case study to describe how digital technology and systems can assist in every aspect of the caring economy. This includes the client being certain of the detailed care they will receive, carers having more time to properly connect with their clients as digitised systems reduce administration and governments having the data to understand the effectiveness of their programs in real-time and make adjustments as necessary.
These outcomes are not achievable without better data and records, as Tim Kelsey (Analytics International HIMSS) highlights in his contribution on the digitisation of health. As he notes, the priority for Australian governments in developing a single, lifetime comprehensive record that follows the patient wherever they are treated is to agree on common data standards for clinical information. This would include the adoption of the Individual Health Identifier (IHI) as the primary identifier for all medical records. The IHI, a federal initiative, already provides a unique 16-digit number for all eligible residents in Australia and should be used by state and territory governments as well as private providers as the de facto standard for all health and care services.
But joined up data and records alone will not drive the innovation and improvement necessary to deliver the best care possible. Jordan O’Reilly (HireUp) reminds us that just like other sectors of the economy, human services, such as disability care, need innovative risk-taking and the entry of new firms. O’Reilly suggests governments can play a market steward role by connecting entrepreneurs, facilitating the broader distribution of funding and investment in new models, building awareness of innovators and incentivising research and development.
Where new firms, data and technology emerge to improve service delivery and outcomes for the community, it is important to share their benefits more broadly. As David Spriggs (InfoXchange) explains, this is beginning to occur in the provision of homelessness services. But there remains a compelling case for embedding proven systems across all jurisdictions and the housing continuum for safe and reliable access to shelter. This requires:
Building on the New South Wales and Tasmanian approaches to implement a national approach to service coordination across the homelessness sector, so that services have a simple way to update and share bed vacancies, refer clients between services and with appropriate consent be able to view client information across services.
Leveraging the Queensland approach to implement a client management system that is enabling a more person-centred, integrated approach across the housing continuum, including homelessness, social housing, affordable and private market rentals.
In sectors such as justice that have long been dominated by paperwork and face-to-face proceedings, there is a need to build momentum for change, starting with high-volume and low complexity matters in the civil space. Sarah Kaur (Portable) proposes that governments invest in new processes and online tools for the most common disputes about residential tenancy, small consumer goods, fencing and traffic offences.
The rise of mental health concerns during COVID-19 and the recent Productivity Commission report into mental health have built momentum for fundamental changes to the way mental health services are delivered in Australia. The provision of these services via telehealth has demonstrated the immediate opportunities to provide better access to these critical services. Professor Mary Foley (Telstra Health) notes that we must maintain the momentum and learn from countries that already have telehealth and virtual care embedded in their systems for mental health care.
These contributions demonstrate that there is no shortage of ideas and enthusiasm for using technology and data to deliver better human services. It is now time to build on the momentum of the COVID-19 pandemic and use technology and data to deliver human services that meet community expectations and enhance the sector’s contribution to our economy and our society.
Click below to explore each topic and author contribution.
The following scenario illustrates the benefits of digitising health and human services.
Tom has an acquired disability which limits his ability to totally self-care. He requires assistance in household duties, personal care and maintenance of his affairs. He lives in a supportive accommodation setting in the community. Through a National Funding Scheme (which would incorporate the various schemes available now for community support) he has a tailored and detailed system of care which allows him to live as full and independent a life as possible. This is enabled by an integrated approach of virtual and physical care components. Tom is empowered in knowing that he has support. This comes in the form of chat bots that steer him through daily challenges, smart home design that facilitates his daily activities, monitoring and measuring of his achievement of specific tasks and regular targeted visits by his care team virtually and physically. The technology frees up the carers to give Tom more emotional and personal support.
Mary works for the Community Care Company that provides many clients in the community with specialised health and care needs. She has a range of clients in facilitated self-care accommodation and receives regular updates on how they are faring and what challenges may be emerging through a dashboard of measures. She can contact clients virtually or physically as required. The contacts are electronically detailed, and the quality metrics of care are autonomously collected, allowing for effective communication with GPs and other health teams. Importantly, in this possible future scenario, the charging codes to the various government funding schemes are linked for auditing and accounting purposes.
Tracy is the manager of community services in the state Health and Human Services Department. The scheme to provide care to the significant number of community members under Government assisted care programs is demonstrating its quality and effectiveness, reassuring herself and her team. Importantly the privacy of the clients and the carers are protected, client-driven targets are regularly measured and supported, and the financing of the system is transparent and accountable. Importantly if deviations in expected care levels are identified, they can be corrected rapidly and accurately.
We can achieve these scenarios today by digitally enabling the care system through a supported and validated approach. Support refers to an appropriately skilled workforce, infrastructure and financing, while validation will need the standardisation of the collection, storage, security and interoperability of data. What is clear is that this digital transformation can improve the management of care, the measurement of the activities performed and the monitoring of the quality of care.
However, we face some key challenges in bringing this scenario about. These include the complexity of human services, the need for a sustained financial and strategic investment, and a well-executed change management process.
Applying a digital overlay to human service is not as simple as shifting to a digital transaction as we have seen in other industry sectors – a wide range of building blocks need to be in place. These include consumer engagement, workforce development and skillsets, infrastructure provision, finance models, data management and governance, legislative and ethical requirements, monitoring and evaluation, operational frameworks and standards.
In order to achieve the scenario outlined above, we need to focus on the two most challenging steps: data governance and workforce enhancement.
Many lessons have been learned over the implementation of the MyHealth Record system, but it also has to be appreciated that the health and care system had been dealing with data and its management for many years. What is needed to progress from this point is refinement and implementation of a solid rational approach to data management. This includes data standards, the validation of various data inputs, the rules for data analysis and the secure messaging between data entry points. The research in this area has progressed significantly to provide secure and privacy-assured systems to back the service models currently in action.
Dealing with workforce capabilities is a complex challenge. The Australian Digital Health Agency has just released a roadmap detailing the steps required for the national digital health workforce. There is an urgent need to reskill the existing workforce, to support the adoption of digitally-driven care systems and to create new roles in the health and care systems that will enable this transition.
Australian governments agreed a national digital health strategy in 2017 and significant progress has been made – My Health Record provides citizens and their care professionals with online access to key health information; a set of interoperability principles have been developed; and standards to enable secure digital communications between providers have been developed and tested (raising the real prospect of an end to the use of fax machines in clinical practice).
Australia needs to build on these foundations to implement nationwide interoperability and, in time, empower a single, lifetime comprehensive health record that can be shared between all health providers and is accessible to the resident or citizen whenever they choose. This would be a dynamic platform to support care co-ordination and clinical decision making – and also empower people to take more control of their health and wellbeing when they choose to. It would empower them to share their data, if they choose, for research into new treatments and medicines.
The first priority for Australian governments in developing a single, lifetime comprehensive record is to agree on common data standards for clinical information – including adoption of the Individual Health Identifier (IHI) as the primary identifier for all medical records. The IHI, a federal initiative, already provides a unique 16-digit number for all eligible residents in Australia – this should be used by state and territory governments as well as private providers as the de facto standard for all health and care services. In this way, data can follow the patient wherever they are treated and improve the value of health data for analytic purposes, empowering insights into the quality of care provided and its effectiveness.
Around 250,000 people each year are admitted to hospital because of a medication error – principally because the clinician prescribing the medicine doesn’t have access to their patient’s paper medical record and makes an inadvertent mistake. Digital records can be shared safely in real time, reducing the risk of medication error. Digital health is a clinical, social and economic priority – improving the safety and effectiveness of care while reducing the administrative burden on frontline staff as well as waste and duplication in clinical practice. It is also a human imperative, supporting people to make the right health and care choices for them. COVID-19 has underscored how important this is – the availability of virtual care and telehealth services to keep people safe when they needed medical attention has been transformed during the crisis. Maintaining the momentum of these digital services requires ongoing political and financial commitment to embedding the principles and standards of interoperability in Australian healthcare.
In many respects, Australia is a global leader in digital health – at national and jurisdictional levels. My Health Record is an example and, in particular, its far-sighted guarantee that an individual can control who else sees the information it contains. Sharing information more comprehensively to connect the national health ecosystem will yield extraordinary social and economic benefits – not just in supporting the sustainability and quality of services in an age of fiscal constraint and demographic pressure, but also in empowering innovation and enterprise and the development of new digital industries.
The COVID-19 pandemic has been an inflection point for digital health and is likely especially to be so for the delivery of mental health services.
COVID-19 has increased levels of anxiety, depression, stress and isolation and these impacts have been exacerbated by job loss and the significant financial loss many have experienced. In May this year, the World Health Organization used the pandemic to call for the scaling up and reorganisation of mental health services on a global scale in order to build a mental health system that is fit for the future.
This is especially concerning when you consider that members of the Royal Australian College of General Practitioners reported before the pandemic that mental health was the most common issue for which patients seek care. Already, we know from the Productivity Commission’s draft report on mental health from October 2019 that, conservatively, mental ill-health and suicide has an economic impact exceeding $43 billion per year.
If there is a lesson for mental health service delivery from this, it might be that digital technology can help us deliver healthcare flexibly, reducing isolation and improving social engagement and connectivity.
In mental health, a unique challenge this pandemic has presented is that the impediment to accessing services is universal, ignoring some inequities that exist across health systems such as the regional/rural divide, as even metropolitan services cannot provide care using their established models.
Supported by good digital solutions, governments and healthcare providers have responded quickly to establish new models of care, some leveraging existing resources utilised in new ways, and others combining solutions to deliver entirely new models.
At Telstra Health we have been working in a range of ways to support governments and healthcare providers during this period, including supporting mental health and alcohol and other drug (AOD) services in new initiatives.
New models of care during the pandemic have included enabling GPs and specialists to provide care to their patients using telehealth, supported by electronic health records that can be more easily shared. In addition to being safer during the pandemic by limiting unnecessary in-person interactions, access to telehealth has been an important tool to maximise access to mental health care at the GP and elsewhere.
An example of the way technology can be applied would be utilising telehealth or virtual consults where clinically appropriate over in-person consultations, and then using digital patient flow solutions to plan hospitals admissions and stays with the additional challenges of social distancing and other preventive policies in place.
One of the huge potential benefits of the acceleration of this digitisation is that as we enable people and information to be better connected, and when we connect across traditionally disconnected components of the health system, it improves clinical outcomes, quality, access to care, safety, and importantly, patient experience.
Digitising and connecting these systems can also lead to significant productivity improvements in health, making Australia’s health system more financially sustainable without reducing quality. Another often overlooked aspect of digital health is that digitisation of health information not only supports direct clinical care and self-care for patients, but also enables continuing improvement for health systems and clinical research.
Change in healthcare is often incremental and always complex. But we have an opportunity to accelerate and embed the positive change and innovation that has come about in response to COVID-19.
With changes to telehealth being reviewed consistently, let’s not lose sight of the long-term benefits and opportunities that telehealth and virtual care solutions can provide. Especially, we should be conscious of what we can learn from countries that already have telehealth and virtual care much more embedded in their systems for mental health care.
Supporting digital health, and creating high quality standardised electronic health information, carefully managed within privacy frameworks, will increase the flexibility and equity of the care we can deliver, and ultimately, support the sustainability of our health system into the future.
In 2018-19, Specialist Homelessness Services agencies provided support to over 290,000 clients in a variety of different circumstances.
A recent study from the University of Melbourne highlighted the economic, health and social costs associated with homelessness and the lack of service coordination. The report estimated that one person experiencing homelessness in Victoria costs $25,615 per year when considering health, crime and other factors. The need for digital solutions to support vulnerable community members has been cited repeatedly across government strategies including the WA Government Homelessness Strategy and the NSW Domestic and Family Violence Prevention and Early Intervention Strategy 2017 – 2021.
“People have to go to so many services, and they might not have any places, so they get sent back. Services need to communicate better with us to let us know how many beds are available. If there aren’t any beds available, we need to know on the spot, so we don’t waste our time, looking here, looking there and missing out.” – insights shared by a user of homelessness services during an Ask Izzy co-design session.
The COVID-19 pandemic has brought about countless changes to daily life in Australia, not the least of which is the acceleration of digital transformation across many industries.
It has also precipitated a move to the use of real time data as a way of measuring need and impact, as governments and the community sector increasingly rely on this information to plan their response.
Digital platforms like Ask Izzy have fundamentally changed how many Australians experiencing or at risk of homelessness access housing and support services. The mobile website developed by Infoxchange in partnership with Google, realestate.com.au and News Corp Australia now supports more than 200,000 requests for help every month.
The real time usage data from Ask Izzy has been providing valuable insights into how the needs of the public changed at the outset of the pandemic, with massive increases in people searching for food and Centrelink assistance.
Technology has also been a significant enabler for services in the homelessness sector. The Specialist Homelessness Information Platform (SHIP) developed by Infoxchange in partnership with the Australian Institute of Health and Welfare (AIHW) supports over 1,500 homelessness services in Australia to manage client data, measure outcomes and report to funders.
Several jurisdictions have extended the use of SHIP to enable service coordination including consent-based sharing of client information between services, common assessment tools, electronic referrals and sharing of vacancy information.
SHIP has also been used to collect data specifically for COVID-19 by allowing case workers to record if clients’ health or finances have been affected by the pandemic. This data has been providing invaluable insights into what is happening within the sector during this crisis, and how it is affecting people accessing homelessness services.
Despite these advances there are still significant gaps that need to be addressed before we can break the cycle of homelessness. Technology and data can enable much-needed reforms in putting the person in need at the centre of the service system, enabling greater coordination between services and better understanding service demand across the sector.
Connection with a real person who can help will always play a crucial role in supporting people who are experiencing homelessness. Digital technology should not be used solely to reduce the cost of services or to replace the role of case workers, but to improve services for people in need and to inform data-driven decision making in the sector.
There needs to be a national approach to service coordination across the homelessness sector, so that services have a simple way to update and share bed vacancies, refer clients between services and with appropriate consent be able to view client information across services.
These capabilities already exist in the Specialist Homelessness Information Platform (SHIP) and have been leveraged by the Housing Connect program in Tasmania and the Going Home Staying Home reforms in New South Wales.
The Queensland Government has taken this a step further by implementing a client management system that is enabling a more person-centred, integrated approach across the housing continuum including homelessness, social housing, affordable and private market rentals.
We can take lessons and insights from a number of these jurisdiction-based initiatives. By sharing what state and territory governments are doing independently and working together based on those learnings, we can work towards a national approach with proven strategies that are known to deliver positive social outcomes.
We also need to enable case coordination and electronic referral that go beyond housing and homelessness services into the broader health and human services sector, as we know that people in need are often experiencing many challenges including financial distress, family violence and mental health issues.
Government can play a key role in unlocking data for the sector. The Housing Data Dashboard released by the Australian Institute of Health and Welfare (AIHW) is a good example of bringing together datasets from multiple sources to provide insights on housing and homelessness.
We need to build on these solutions to move towards a more real-time and predictive view of data, incorporating service demand from platforms like Ask Izzy and enabling a more responsive service system.
The value of real-time data has been shown during COVID-19. Government can now take a leadership role supported by the sector to build on this work and develop a national data sharing strategy to support a more responsive service system.
The ability to respond to the needs of people experiencing homelessness, across a well-coordinated community and health support system is essential to reaching our goal of functionally ending homelessness.
Digital innovation is long overdue in the service system, and the delivery of solutions designed with people with lived experience of homelessness and service providers is critical.
People experiencing homelessness would benefit from a system that truly puts them at the centre and responds to their needs without them having to repeat their story to multiple services.
This approach would bring more efficient use of resources in the homelessness sector, help people sooner and move us closer to ending homelessness in Australia.
The need for integration of technology into our justice system has been felt keenly over the past few months. Courts and tribunals around Australia have hit the pause button for all but the most urgent matters while trying to provide core services during the coronavirus pandemic. In Victoria, billions of dollars are potentially held up from being released into the construction industry as the Planning and Environment list at the Victorian Civil Administrative Tribunal (VCAT) suspended in-person hearings from March. In response, the Victorian government has provided $5m for VCAT to transition from paper-based and manual systems to an end-to-end digital way of resolving these matters, including online dispute resolution and virtual hearings.
Such rapid change doesn’t happen in the justice sector, or at least, it didn’t use to. Like VCAT, more government justice organisations will benefit from re-thinking how technology can provide easier access for the communities they serve, before the next crisis.
Digital resources, tools and services can provide communities access to legal information, education, and help with lower barriers during the coronavirus pandemic, and well after it passes. Digital tools present opportunities for interactive, guided, and personalised pathways for people with legal issues who can help themselves through different parts of the process of resolving a legal matter.
As consumers of core services that have been provided online for years, large segments of communities have adapted to “self-serve” style digital interactions with companies and government agencies to gain access to utilities, education, health, tax, and other services. The time for re-thinking how justice may be accessed through “self-service” is now, because this model scales in a way the justice system cannot currently, in order to meet growing demand.
Not all in our community are equipped to navigate their legal affairs without in-person support. We need to prioritise in-person support for those who need it, including those who may be in complex and vulnerable situations. However, for those who can, and want to help themselves through the process, we must design clear and user-centric digital legal services that can be accessed without manual intervention and are available outside of business hours.
While almost all government services have an online presence and provide some resources online, too often they are not presented in a way someone with limited prior knowledge of the law can use, interact with, or understand easily. This leaves people reliant on in-person assistance to work through their issues.
Introducing innovation in the justice system is hard, but the economic and accessibility gains are harder to ignore. Starting with high-volume and low complexity matters in the civil space can represent a low-risk path to introduce new processes, and online tools to the benefit of many. Disputes about residential tenancy, small consumer goods, fencing, and traffic offences represent areas where pilots to increase access to justice through digital transformation can and should be supported by government funding and human-centred design practices.
Introducing technology that allows people to resolve their issues with more ease, would lower the backlog in courts, reduce pressure on legal aid, and potentially lessen the expense of engaging private lawyers for the missing middle. This helps to triage the demand of government services, so that organisations are more able to provide one-to-one or high-touch support to people in complex or vulnerable situations who need it.
The world is becoming increasingly digitised, and human services are not immune to the rapid and seismic changes this can bring. While this is an exciting time for innovation – and at Hireup we aim to be at the forefront of innovation in the disability sector – in human services more broadly there is a risk of a growing digital divide.
Without targeted government intervention, access to the positive outcomes of digitisation could be distributed unevenly. If that happens, we could witness the digital divide playing out in a range of harmful ways.
Human services are used by the whole community, and often those with the least access to technology need them the most. That’s why we need governments to take an end-to-end strategic approach to digitisation in human services. This will ensure the benefits of digital innovation are spread fairly amongst sectors and citizens.
A five-point plan for end-to-end government measures could include:
We tend to focus too much on data and not enough on innovative risk-taking. A well-developed ecosystem approach to supporting early stage innovation will enable new ideas to blossom. In human services, we also need to include people with lived experience who often have unique ideas to address persistent problems. We should be aiming to become an ‘innovation nation’, not just in traditional sectors but for the human and social services sector too.
For governments, a key role in facilitating this ecosystem could be to take on a ‘market steward’ role. Through market stewardship, governments can build confidence in early innovation projects and act as a focal connection point – for example, in connecting entrepreneurs with learning, development, funding and scale up support.
Governments need to source great early stage ideas in human services and invest in them. Initiatives could include helping to link up accelerators and incubators and providing seed funding through a grants program. A great step forward in this area is the new social impact investment agreement between the Commonwealth, and states and territories – this program could be leveraged to fund an innovation stream of social impact projects. Without investment at the early stage of human services enterprises, the sector will lag behind others, to the detriment of service delivery and positive social outcomes.
New enterprises benefit from successful examples that can help lead the way for newcomers and make inroads into new markets. Since starting Hireup in 2015, we have witnessed a range of new digital platforms begin to serve people with disability. Government should look to promote successful models in human services and use grants and rollout funding to support them to serve a greater breadth of citizens across the country. Government should learn from successful incubator models and apply this to target social impact innovators in human services sectors.
Governments need to address the problem of uneven access to technology resources that allow organisations and individuals to take full advantage of digitisation opportunities. Driving fair and equal access to training and resources will ensure we avoid the worst possible outcomes of a digital divide.
As more service providers and support services move online, government initiatives could include targeted digital literacy training using public-private partnerships such as the successful NSW program, ‘Tech Savvy Seniors’. Governments could also facilitate better access to technology by tying funding for subsidised devices to the completion of digital literacy training. Targeted support for members of the community who are unable to access a device or computer, or adequate broadband speeds, will promote wider engagement in online service delivery across a range of human services.
Finally, governments should promote the sharing of experiences and research, and support collaborative projects for good ideas in human services. This role could be tied in with the above-mentioned market steward role for governments, allowing the public sector to both facilitate and benefit from collaboration and learning.
Digitisation is changing the world, and while some sectors and cohorts of the community are experiencing great benefits, we must be mindful to spread the benefits to all citizens. Less glamorous sectors, such as those providing health and social services, should not be left behind in the digitisation revolution.
Human services are essential services, so governments must ensure they are a central feature of ongoing digital transformation. Imagine if ten years from now we are talking about how the 2020s saw the development of a truly national, effective Australian innovation ecosystem, where service delivery to citizens is the envy of the world and the benefits are spread right throughout the community.
That’s digitisation done right.