Health Submissions

Submission to the NSW Whole of Government Ageing Strategy

CPSA's submission to the Whole of Government strategy that aims to meet the needs and aspirations of people as they age.

Summary of Recommendations

  1. That universal design features be applied to all social housing.
  2. Apartments for Life model be adopted as an alternative to premature nursing home admission.           
  3. Rebates and incentives should be given in order for dwellings to be age-proof and easily and cheaply adaptable as required.
  4. That incentives be provided to health workers to transfer and/or remain in regional locations. It is important that the development of local economies within regional areas is encouraged to ensure that truly liveable communities are established.
  5. That health promotion services be expanded to enable informed decision making by health users themselves, including peer education initiatives.
  6. That the NSW Government work with key stakeholders, including local governments, community groups and individuals towards improving the accessibility of public transport infrastructure.
  7. That greater funding towards Disability Standards be made to hasten the meeting of benchmarks as set out under the (Australian) Disability Discrimination Act 1992.
  8. That the NSW Government ensure there are effective mechanisms for community consultation, with a particular focus on establishing the diverse needs of older people, when planning changes to public transport services.
  9. That NSW Health increase funding for non-emergency health-related transport services.
  10. That the NSW Government investigate a variety of transport options, including Demand Responsive Transport, with key stakeholders including public transport authorities, the CTO, CT providers and taxi companies, as well as local governments, community organisations, and transport users.
  11. That a NSW older abuse hotline be established, staffed by registered social workers in line with those already in operation in the ACT and Queensland.  It should provide not only referral services but ongoing support.

Introduction

CPSA was founded in 1931 in response to pension cuts. CPSA is a non-profit, non-party-political membership association which serves pensioners of all ages, superannuants and low-income retirees. The aim of CPSA is to improve the standard of living and well-being of its members and constituents. CPSA has approximately 138 Branches and affiliated organisations with a combined membership of over 30,000 people living in all parts of NSW.

CPSA welcome the opportunity to comment on the NSW Whole of Government Ageing Strategy. In developing a whole of government strategy that aims to meet the needs and aspirations of people as they age, it is first and foremost important to note that, as with the rest of the community, older people are represented by a diversity of culture and language, religion, sexuality, residential location, interests and life experiences. The development of policies, delivery of services and ongoing community consultation must therefore recognise that people ‘age’ differently because of these differences and are not a single, homogenous group.

Liveable Communities

Affordable and Age-proof Housing

Maintaining independent living for as long as possible is an important priority for most older people. Meeting the current and future needs of older Australians is as much about maintaining health, mobility and family connections as it is about dwelling type, income and housing costs. Location preferences for older Australians are also likely to be affected as ageing parents seek to be nearer to their adult children and vice versa.

While the oldest households  (those with a reference person aged 65 years and over) have the highest proportion of home owners without a mortgage (79 per cent), people over the age of 50 make up the largest age group of social housing tenants in Australia, at 35 per cent of all social housing residents. Those over 65 make up 18 per cent of tenants.[1]

While only 6 per cent of people over 65 are in private rental housing, they are paying, on average, the highest proportion of their income in rent – over 30 per cent - more than any other group of renters. This indicates that while older renters make up a small proportion of the overall rental market and of the older population, they experience a disproportionately high amount of housing stress. Only 1 per cent of renters over 65 are not in either social housing or receiving rent assistance.[2]

A key issue with older renters is that they often do not have security of tenure. Only 12 per cent of rent assistance recipients and 8 per cent of unassisted renters have life tenure on their property, with both groups only having lived at their current dwelling for two years.[3] This creates limitations for housing modifications and ageing at home.

Affordability is a critical concern for older people who are considering their options between adequate housing and aged care.  Country-wide, most measures show that households in Sydney face the greatest price pressures, followed by those in Melbourne.[4]  Affordability measures tend focus on relatively narrow definitions of housing costs, specifically direct housing outlays, ignoring the wider costs of living such as electricity and water bills which are related to the quality, form and location of housing and have increased significantly in recent years.

Supply of adequate and affordable housing for older people will be crucial in the coming years. It will need to accommodate people who are looking to downsize their home and who generally have a small amount of savings and superannuation earnings. Adequate age-proof housing would remove the need for people to move into nursing homes just because their home is not properly equipped.  

Core design elements to ensure age-proof housing include:

  1. A safe and continuous path of travel from the street entrance and/or parking area to a dwelling entrance that is level;
  2. At least one step-free entrance to the dwelling;
  3. Internal door and corridors that facilitate comfortable and unimpeded movement between spaces;
  4. A toilet on the ground (or entry) level that provides easy access;
  5. A bathroom that contains a step-free shower recess, and;
  6. Reinforced walls around the toilet, shower and bath to support the safe installation of grab rails at a later date.

Yet these guidelines alone are not enough to ensure that communities remain liveable and accessible to older Australians. In addition to structural changes, other important factors include home security and personal safety through adequate pedestrian crossings, for example; close proximity to transport links and public facilities, shops and medical services as well as access to care as required.

Increasingly older people are made to fit into the level of care that is available rather than the one that meets their needs. There is a disparity between what older Australians are looking for to meet their care and housing needs and what the Government is providing. More than 24,000 applications were made for community care provided in the home in 2011, with only 1,698 places offered.

Alternative housing options that foster liveable communities include the ‘Apartments for Life’ project. Originating in the Netherlands, it assumes that 95 per cent of people who are in nursing homes do not need to be there. Models like this create an opportunity to phase out nursing home reliance. Each Apartments for Life complex has a village square at ground level with a range of services and facilities such as banking services, a fitness centre, hair dresser, a physiotherapist, medical centre, gardens and a supermarket.

The model of Apartments for Life in Australia, as is underway in Bondi, is a positive alternative to places such as retirement villages, which have built their financial model on the expectation that residents will move on to an aged care facility as they age.

Recommendation: That universal design features be applied to all social housing.

Recommendation: Apartments for Life model be adopted as an alternative to premature nursing home admission.

Recommendation: Rebates and incentives should be given in order for dwellings to be age-proof and easily and cheaply adaptable as required.

Equitable Health Services and Health Promotion

All health services must be accessible to all consumers – something that becomes increasingly problematic for some people as they age. Australians should have universal access to appropriate health services on the basis of health needs, not the ability to pay or geographical location. CPSA opposes a two-tier system of health care where those using the public system receive inferior services and face unacceptably long waiting periods while those with the ability to pay for private health services receive a higher standard of care.  Similarly, CPSA is opposed to the disparity between the quality and quantity of health services provided between regional and urban areas.

Many older people are downsizing their homes and moving out of urban areas to regional locations in order to affordably be able to age-well within their own homes. It is therefore important that health services are expanded to meet the resulting increase in demand for services within outer areas. Government figures show that the next generation of older people will increasingly live in low-density outer suburbs and outer regional areas. NSW local areas with the highest proportion of people aged 65 years and over are Great Lakes (38.4%), Hastings and Eurobodalla (37%) and Bombala (37.3%).

There is a need to invest in a sustainable health workforce that is geographically dispersed to provide safe, high quality care to all people regardless of their location. Age specific health services will become crucial as older people begin living in more isolated communities and further away from family support systems.

Those consumers who are currently forced to travel long distances to access health care must be adequately catered for. Current public transport systems are inadequate, particularly for those suffering illness or who are frail-aged. Often overnight visits to urban hubs are required as transport services are inadequate in enabling day trips due to timetabling.

There is a need for more community participation in health and community services, and older people should be involved in meaningful consultations, not only about their personal health but within local planning for necessary services. Health users themselves are best placed to determine what services are needed and how they are best able to access them easily. For this to happen, people require access to comprehensive education in order to obtain a sound knowledge base on which to make informed decisions. A greater expansion of health promotion services is required to make this possible.

Recommendation: That incentives be provided to health workers to transfer and/or remain in regional locations. It is important that the development of local economies within regional areas is encouraged to ensure that truly liveable communities are established.

Recommendation: That health promotion services be expanded to enable informed decision making by health users themselves, including peer education initiatives.

Infrastructure and Amenities

Further work is needed to improve the accessibility of footpaths, roads, buildings, public spaces and public transport infrastructure. The Government’s further investment in the Easy Access Program for train stations is welcome. There are also major issues, particularly in rural and regional areas. Although, public transport services meet the five-year benchmarks for accessibility set out under the (Australian) Disability Discrimination Act 1992, many barriers to accessible transport remain for older people.

Access issues included:

  • Few low-floor accessible buses in non-metropolitan areas;
  • some routes having accessible services in one direction, but none on return journeys;
  • some routes offering only one accessible vehicle in the morning and one in the afternoon, limiting flexibility for passengers;
  • when accessible bus services break down they are often replaced by non-accessible buses;
  • hydraulic ramps are found to be out-of-order, and the bus still runs on the route with the non-functioning ramp, without a manual ramp to compensate;
  • non-compliant bus stops and train stations prevent passengers with mobility impairments from using accessible services;
  • stops that comply with access standards are not accessible themselves;
  • in many rural and regional areas, bus stops are on unsealed roads; and
  • the height of bus stop platforms in rural and regional areas is inconsistent making it difficult to use bus ramps properly.[5]

Recommendation: That the NSW Government work with key stakeholders, including local governments, community groups and individuals towards improving the accessibility of public transport infrastructure.

Recommendation: That greater funding towards Disability Standards be made to hasten the meeting of benchmarks as set out under the (Australian) Disability Discrimination Act 1992.

Participation

Transport

Transport is fundamental in ensuring access to services, supporting participation in civil society by maintaining connections with family and friends and engaging in community activities. Transport is a key part of supporting the physical and emotional health and wellbeing of older people. In spite of this fundamental role played by transport, many are unable to access and use the type of transport services that meet their needs.

It is not difficult to argue that NSW is a heavily car dependent state. This is reflected in the funding allocated to major road projects, compared to that allocated to public transport and Community Transport (CT). Car dependency has a major negative impact on all in an effected community, including higher travel costs and greater expenses associated with car ownership, greater health costs and greater costs to build and maintain road infrastructure. As the population ages, there are going to be a greater number of people no longer able to drive. A greater focus on public transport – as well as related infrastructure – is required if we are to ensure that older people are not isolated from community participation in the future.

One of the major concerns of older people is that public transport services have increasingly prioritised commuter services – services in peak hours directed to central business districts – at the expense of non-peak hour services or services that travel through residential areas. In many areas, there has been a modification of bus routes along more major thoroughfares as well as a reduction in the number of bus stops. In rural, regional and outer urban areas there are often very few services, often leaving those who don’t or cannot drive or afford a car unable to get around.

Recommendation: That the NSW Government ensure there are effective mechanisms for community consultation, with a particular focus on establishing the diverse needs of older people, when planning changes to public transport services.

To some extent these sort of ‘holes’ in the public transport system were meant to be filled by Community Transport (CT). The original purpose of CT was to assist older people and people with a disability unable to use public transport or private vehicles to attend social and recreational outings. However, the streamlining of public transport services has meant CT is under increased pressure to assist people who had previously been able to travel on public transport.

There has also been a growing demand on CT for health-related transport particularly due to a lack of funding for non-emergency health transport services. This is placing pressure on CT providers to reduce their services in other areas. CT was designed to support social inclusion, but it is increasingly becoming a service that facilitates health-related transport needs.

CPSA welcomed the NSW Government’s decision in increase funding for the Community Transport Program. However, the lack of targeted funding for health-related transport programs as well as previous changes to public transport services will continue to result in CT failing to meet demand.

Recommendation: That NSW Health increase funding for non-emergency health-related transport services.


Another issue is that CT cannot always meet the needs of those who use and need it. Generally, most people are able to access CT once a week. Services can be expensive because while no one is refused service because of inability to pay, CT services usually come at a much higher cost than public transport, costing around $5-$10 a round trip. It is also the case that some people who become unable to access public transport services because of changes cannot use CT services because they are ineligible.

It is therefore important that alternate modes of transport service delivery are investigated with the aim of eliminating transport inaccessibility.

One such mode is a comprehensive roll-out of Demand Responsive Transport (DRT) services. DRT offers a combination of fixed route and demand responsive services, enabling passengers to be picked up and dropped off anywhere along or within the bus route or zone. This allows people who are unable to access traditional bus services due to distance or mobility difficulties to continue to independently go about their day-to-day activities. DRT has the power to significantly reduce the ‘360m gap’, ensuring everybody has access to appropriate transport services.

Where DRT is offered as part of CT operations, the cost of CT services can be reduced because DRT makes more efficient use of service capacity. It also pools available transport resources (drivers, cars, buses, etc.) to deliver services that are appropriate to the needs of clients.  If DRT is integrated with traditional public transport services, demand for CT can be relieved and CT providers would therefore be able to focus on maintaining and improving the independence of those who most need their services in line with the original intention of CT. Depending on the format of the DRT or other services and who is charged with providing them, legislation may be required as DRT and CT are not covered by the NSW Passenger Transport Act 1990.

Recommendation: That the NSW Government investigate a variety of transport options, including Demand Responsive Transport, with key stakeholders including public transport authorities, the CTO, CT providers and taxi companies, as well as local governments, community organisations, and transport users.

Discrimination, Security and Dignity

Abuse of Older People

Evidence has shown that around 50,000 people aged over 65 are being abused in NSW, according to a study by the Australian Institute of Criminology, and this figure could be significantly higher depending on the definition of ‘abuse’ used.

Abuse of an older person is defined by the World Health Organisation as any behaviour that causes physical, psychological, financial or social harm to an older person occurring within any relationship where there is an expectation of trust between the older person and the abuser. Abuse may involve a single act, repeated behaviour or neglect. It can take the form of financial abuse, emotional or psychological abuse, or be of a physical, social or sexual nature. Of these, financial abuse of older people and neglect are the most common, yet often the most difficult to detect. Even physical abuse is very common but not always recognised.

Violence and abuse against older people is often compounded by the following issues:

  • The on-going impact  of past abuse on mental, emotional and physical health;
  • Poverty, disability and/or increasing frailty and dependence;
  • It is often hidden by a culture of silence and stoicism;
  • It can be exacerbated by ageism.

In particular, the more vulnerable and dependent the individual, the fewer resources they are likely to have to confront and escape their situation, especially when family members are involved.

While CPSA understands that measures are in place for people to act on abuse through contacting authorities such as police, as outlined in the NSW Interagency Protocol for Responding to Abuse of Older People, a support service that assists victims to work through the ongoing psychological and emotional repercussions of abuse is lacking. People who have suffered abuse are often reluctant to deal with figures of authority, so speaking to police or government workers is inappropriate. Social workers trained in this sensitive area are needed to adequately deal with the repercussions of older people abuse that can last much longer than the incident or period of abuse.

An effective older person abuse hotline could not just be for the abused but also be a contact point for people who have witnessed or believe that an older person is being abused to seek advice on how to act. It could walk the caller through referral services and give ongoing support. Importantly, due to the sensitive nature and trauma associated with abuse, it is important that this is a line of its own, not linked to a call centre, so that callers can be linked to a social worker trained in the area immediately, similar to how the Domestic Violence Line (NSW) currently operates.

Older people constitute a significant proportion of the NSW population and have the right to safe environments and respectful relationships with their families and communities.

Recommendation: That a NSW older abuse hotline be established, staffed by registered social workers in line with those already in operation in the ACT and Queensland.  It should provide not only referral services but ongoing support.



[1] ABS, Australian Social Trends – Housing Assistance for Renters, September 2011 http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4102.0Main+Features10Sep+2011#WHOLIVES

[2] ibid

[3] ibid

[4] Australian Government (2011) National Housing Supply Council State of Supply Report, Department of Sustainability, Environment, Water, Population and Communities, Canberra, p. 114.

[5] The Allen Consulting Group, (2007), Review of the Disability Standards for Accessible Public Transport – Draft Report