Part 2: Strategy to guide the delivery of home-based support services

Home-based support services for older people.

In this Part, we examine:

Summary of our findings

The current Strategy has been in place for nine years. Although it provides a clear direction for DHBs, not all DHBs are clear about how to achieve some of its objectives. Supplementary policies are also not clear about how their objectives should be achieved. As a result, the strategic and policy framework is unclear.

Progress in implementing the objectives in the Strategy appears to vary between DHBs. However, a lack of performance information prevents us from forming a firm view of the progress that has been made throughout the country.

Delivering quality services that meet people's needs and provide value for money requires clear strategies and policies. In our view, the absence of complete, reliable, and comparable performance information on the delivery of services will make it harder for the Ministry and DHBs to prepare effective policies and strategies to support service delivery.

Health of Older People Strategy to guide the delivery of home-based support services

DHBs are receiving mixed messages from the Ministry about the status of the Strategy and what they ought to be doing.

The Strategy was published in 2002 to implement the objectives of the New Zealand Positive Ageing Strategy (April 2001). That strategy included objectives that services should support older people to live independently at home and should be provided to those in need in a consistent way. Therefore, one of the main aims of the Strategy is to develop an integrated approach to health and disability support services that responds to older people's varied and changing needs.

Through the Strategy, the Ministry and DHBs aim to deliver home-based support services that, in summary:

  • support older people living at home where sustainable;
  • respond to older people's varied and changing needs;
  • are provided in a consistent way; and
  • are integrated and co-ordinated with other health services.

These policy objectives have provided a clear direction for the delivery of home-based support services. However, in our view, the Ministry has not provided DHBs with enough guidance and direction on how to implement improvements under the Strategy. There has been some confusion about how DHBs are to implement the policy objectives.

For example, the Operational Policy Framework 2010/11, which is one of the main documents setting out the Ministry's requirements of DHBs, required DHBs to work towards implementing a restorative care approach. Restorative care is a model of care focused on, where possible and appropriate, restoring an individual's capability after an illness or other health setback and therefore restoring their quality of life. A more traditional approach would involve providing support to an individual to perform daily living tasks. A restorative care model aims to rehabilitate an older person so that they can return to carrying out those daily tasks themselves. In some instances, restorative care can minimise costs by reducing the need for home-based support services or expensive residential care.

In our view, the Ministry does not have a clear mechanism for ensuring that DHBs consistently implement a restorative care approach when it would be appropriate to do so. It is not clear how DHBs are supposed to implement a restorative care approach or what difference it would make if all DHBs fully implemented this approach.

The annual Operational Policy Framework gives DHBs a certain amount of autonomy in how they deliver services to meet their community needs but still requires them to follow government policy. The Strategy took this into account and provided more direction than prescription in how policy objectives should be achieved. This has given DHBs flexibility in how they deliver home-based support services to meet local needs.

Also, the incoming Government in 2008 pledged changes in line with the National Party's Aged Care Discussion Paper, Choice not Chance for Older New Zealanders. In our view, the Ministry needs to consider how best to integrate government policy with existing priorities and provide DHBs with more clarity about this.

Overall progress made under the Health of Older People Strategy

It is difficult to assess DHBs' progress under the Strategy because the information collected is not complete, reliable, or comparable.

There is not enough information available to form a view on how well home-based support services are achieving each of the objectives listed in paragraph 2.6. The Ministry collects some performance information. However, this information, as with performance information generally, is not complete, reliable, or comparable. The limited information collected does not appear to be effectively analysed by the Ministry to provide national information. There is little information available on the quality of services or whether services are providing value for money.

While we were writing this report, the Ministry released a "stocktake" of information about DHBs' administrative arrangements for home-based support services. Although this "stocktake" gathered information about monetary arrangements – which might provide a basis for assessing the efficiency and consistency of arrangements – it did not assess DHBs' progress with achieving the Strategy's objectives. The "stocktake" has resulted in the Ministry planning a programme of work that includes reviewing audit activity, performance monitoring, and complaints management.

Indicators that progress might have been made

Through our survey of DHBs, we have obtained a limited view of DHBs' progress with integrating and co-ordinating home-based support services with other health services. Some DHBs are taking a more co-ordinated approach to service delivery, considering hospitals, care, and support services together when planning how an older person will receive those services.

Also, the Ministry has actively required DHBs to improve some aspects of home-based support services. For example, the Ministry has required progress in implementing a consistent approach to needs assessment by introducing a standard nationwide assessment tool (InterRAI). We discuss DHBs' progress with introducing InterRAI in Part 3.

Indicators that progress might have been lacking

The Ministry produced information about implementation of the Strategy which shows that progress has generally been slow, with many DHBs at different stages of implementation. Many DHBs have missed a 2010 deadline set out in the Strategy, and services are not yet fully integrated or co-ordinated.

The Strategy provided a framework for DHBs to develop an integrated approach to providing support services for older people. The recent Ministry "stocktake" of home-based support services shows that this has not yet been achieved.

One of the requirements specified in the Strategy was for DHBs to record, in their annual plans, the progress being made towards implementation of the Strategy. A report published in August 2008 by the University of Auckland's HOPE Foundation for Research on Ageing reviewed DHBs' progress in implementing the Strategy. The study found that most DHBs showed minimal evidence of planning for the implementation of the Strategy. The study also found that the barriers to implementation included shortages in both funding and workforce.

The Government has clearly stated that it wants DHBs to provide consistent support for older people to live independently at home. Based on feedback from the Ministry, DHBs, and others we spoke with, DHBs have made variable progress in implementing a restorative care approach and in delivering services in a consistent and equitable way.

Spending on home-based support services has been increasing. There was an increase of 70% during the four years to 2008/09 (to $211 million). This compares to a 35% increase in residential care spending during the same period. However, it is not clear to us whether this increased funding has helped DHBs to implement the Strategy.

DHBs indicated in response to our survey that the amount of funding from the Ministry is an important issue for them in implementing actions in the Strategy. Also, in our view, the lack of complete, reliable, and comparable performance information is making it more difficult for the Ministry to target resources to ensure greater value for money.

Challenges in continuing to manage and support the delivery of home-based support services

An increasingly older population, economic downtown, lack of a clear strategy, and poor performance information combine to put the effectiveness of home-based support services at risk.

As noted earlier, the numbers and proportions of older people are increasing and the economic downturn has put public spending under pressure. The combination of increased demand, more complex support needs, and financial pressures presents a significant risk to the future delivery of home-based support services.

Added to this, the Ministry has not updated or emphasised the importance of the Strategy to ensure that DHBs have clear plans to achieve the desired improvements. The Ministry acknowledges that comprehensive and clear information is required to support DHBs in delivering the Strategy's objectives.

Without such clarity, there is a risk that home-based support services will not be effective and/or consistently delivered to a growing and vulnerable group of people. In our view, the Ministry needs to provide DHBs with clearer guidance to ensure that DHBs fully understand the improvements required to meet the changing needs of older people and deliver services that meet them effectively. The Ministry agrees with our view.

To properly inform and develop policies and strategies, performance information needs to be meaningful and reliable. The Ministry does not have the complete, reliable, and comparable performance information it needs to write better and more targeted policies and strategies. Again, the Ministry acknowledges that this is a significant issue.

The Ministry is in the early stages of developing a more effective approach to collecting and analysing performance information. It expects that information gathered recently from DHBs through InterRAI will support the preparation of policies and processes for collecting comparable performance information.

In our view, the absence of a set of clear key performance indicators prevents the Ministry from effectively monitoring and improving service delivery. In Part 5, we examine some of the ways that information can be used to improve the quality of service delivered.

We also discuss in Part 5 how the Ministry, DHBs, and providers are working together to address some of the providers' workforce challenges associated with continuing to deliver home-based support services.

Recommendation 1
We recommend that the Ministry of Health collect and use meaningful and reliable information to ensure ongoing service quality and value for money of home-based support services by:
  • specifying a set of national key performance indicators for district health boards to measure service performance;
  • working with district health boards on mechanisms to ensure that performance data is reliable and meaningful;
  • using performance data to inform policies and strategies that will help district health boards deliver high quality services; and
  • sharing with district health boards good practice and benchmarks to drive continuous improvement.

Ruth is 82 and has been living in her home for 58 years. She lives alone and is able to do most things for herself. Ruth has received home-based support services for about three years. Currently, Ruth receives three hours of support each week for help with personal care and household tasks.

Accessing and receiving services

Ruth's services were arranged while she was in hospital for an operation on her legs. Services started promptly after she left hospital and she thought this worked quite well.

Ruth has a copy of her care plan, which is updated occasionally. Someone visits to check how she is and what she might need for the coming year. Ruth finds it good to have a plan so she knows what to expect. She has not had any problems with the services she gets but if she did, she would call the organiser named in her care plan.

Ruth's provider usually calls if a different support worker will be working. She recalls one instance when two workers arrived on the same day, but mostly the service works well.

Reducing services

Ruth's support was reduced a while ago. Before this happened, someone visited her to discuss how she was coping. After this visit, some housework support was cut because Ruth was able to do more herself. Reducing support did not worry Ruth because she felt she had improved and did not need more support. She felt involved in the decision to reduce her services and thinks the change in her support was managed quite nicely. If her needs were to change, or if she felt like she needed more, she would probably talk to her doctor or her provider. She would ask for help if she was getting worse.

Being independent

Ruth's goal is to live at home and be independent. Ruth said, "This is definitely what I want to do." She considered that she could look after herself but needed a little help with some tasks that she cannot manage. While she is like this, Ruth wants to stay in her home. Getting home-based support services means she can have a routine, doing things when she wants to do them and in the way she wants to do them. She can be at home, relax a bit, and get some help with the things she cannot do.
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