The adage that the customer is always right presumes that customers know what they want, and understands the repercussions of their choices. In community care, it presumes that older people know what help they need to live in their own home for as long as possible.
The change means that they have gone from being clients to customers, from passive recipients of services to active participants in managing their own care. They have carte blanche on how they spend their budget except they can’t buy food, pay rent or their mortgage, pay for holidays or entertainment or gamble, and they can’t pay family and friends to provide care.
The system will put the older person and their family in the driver’s seat, giving them greater choice and control. It’s hoped this means common complaints about the inflexibility and non-personalised nature of services will be a thing of the past. And transparency of budgets means that customers can try to ensure they get value for money.
Too many choices
But the change has serious, perhaps unforeseen implications. Let me illustrate with an example.
Last week, we went to buy a new television after our ten-year-old set gave up the ghost. I thought hubby and I would just be arguing to balance between size (his priority) and price (my priority).
But we were bamboozled by questions from the salesperson. Did I want a smart TV, inbuilt DVD player, an LCD, LED, plasma or 1080p, whatever that is. We didn’t know about or understand the options.
I think the aged-care customer is in a similarly intractable position.
What does she need to know before being able to make an informed choice? Information about her own clinical needs is important. If you don’t know that you have high-blood pressure, for instance, you may not choose to do anything about it.
Older people living in the community often don’t realise what their clinical needs are. They also may not know the implications of their clinical needs.
They may not realise, for instance, that their poor physical function and declining cognitive ability both put them at greater risk of having to go into a nursing home.
An older person may request that their funds be spent on home cleaning and help with the shopping. But if that person is told that he is at high risk of falling and may benefit from a physical exercise program, he may choose to forgo help with shopping and get the service to select, and pay for their attendance at a seniors’ exercise class.
The Home Care Standards against which community-care providers are reviewed and accredited have not been changed in response to consumer-directed care. So there are no safeguards to ensure that service providers give customers a wider range of choices, and information about the possible repercussions of those choices.
This is problematic in a number of ways and regulation needs to keep pace with changes in care systems.
First, customer satisfaction does not correlate with service quality, and is much more influenced by the relationship customers have with care staff. A patient may be dissatisfied with a curt doctor, for instance, even if her surgery was conducted to the highest standard.
What’s more, a consumer-directed system provides incentives for community-care providers to keep their clients happy, but not necessarily provide the best care to keep them at home longer.
It’s like doctors giving patients prescriptions because it’s what they want, rather than telling them to exercise and lose weight, which would be better for their health overall.
We like easy solutions, not ones that require us to work. Customers want help with housework and gardening, even though in order to stay at home longer, it may be better for them to do these things themselves. It would help them maintain and improve their functional ability, and perhaps even lift their depression.
Better, more appropriate services would be providing retraining people in lost self-care skills, and helping them increase their social network.
Back at the shop, we decided deciding was too hard and now watch television on the computer. Shops should train their salespeople to give digestible information to those of us who don’t know anything about gadgets.
The changes in community-care packages are much more complex and affect whether people can stay at home for the rest of our lives. More needs to be done to empower citizens who have suddenly been turned into customers.
Dr Lee-Fay Low is a Senior Research Fellow in Psychiatry in the Faculty of Medicine, UNSW.
This opinion piece was first published in The Conversation.