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Helping Carers: the National Respite for Carers Program
The objective of the audit was to assess the effectiveness of Health's administration of the National Respite for Carers Program.
In 2003, an estimated 2.6 million people (carers) provided assistance to those who needed help because of a disability.1 This included assistance with self-care, mobility, communication, transport and housework.
The Australian Government and State and Territory governments deliver support services for carers and care recipients. Support services include basic care, coordinated services for those with complex needs, financial support, and respite and information services. Carer-focused respite, information and counselling services are provided under the National Respite for Carers Program (NRCP).
NRCP is a collection of activities arising from successive Australian Government policy and funding initiatives to support a variety of carers in the community. Health has defined NRCP's objective as the support and maintenance of caring relationships between carers and their dependent family members or friends by facilitating access to information, respite care and other support appropriate to their individual needs and circumstances, and those of the people for whom they care.2
Respite care, and associated information and counselling services, are primarily delivered through NRCP's three major components, which are:
- Resource Centres—these Centres act as points of contact for carers seeking information and advice about services and other support and assistance. For example, carers can telephone their nearest Resource Centre, located in each State and Territory capital city, for information on various topics, referrals to a range of community and government services, emotional support and counselling, and for a wide range of resources including a free carers' kit. Resource Centres assisted 42 627 carers in 2003–04;
- Respite Centres—these Centres arrange short-term or emergency respite for carers through existing services. They are also funded to purchase or subsidise flexible respite care, provide emergency respite services, and link carers to residential respite services. For example, Respite Centres are able to provide immediate in-home respite to assist carers in an emergency or unplanned situation, assist carers to access other emergency/after hours services, and arrange ongoing respite if the carer requires emergency assistance for more than a few days. Respite Centres assisted 47 800 carers in 2003–04; and
- Respite Services—these Services deliver respite to carers and the people they support in a variety of settings, including in-home, day centre, host family and other short-term respite accommodation. Respite Services assisted 28 000 carers in 2003–04.
Health does not deliver services directly to carers, with funding provided to a range of organisations to operate NRCP Centres/Services, including community organisations, charitable organisations, State/Territory governments, local government, religious organisations, and private sector organisations.
In 1996–97, the Australian Government commenced funding for NRCP, with Program funding increasing from $19 million in that year to $134.8 million in 2005–06. The most significant increases have occurred over the last three years, including additional funding to expand NRCP target groups. Funds are currently allocated across the three major Program components as follows3:
- Resource Centres—$4.7 million (9 Centres);
- Respite Centres—$46.2 million (61 Centres); and
- Respite Services—$59.5 million (432 service providers).
This funding is part of an estimated $2.5 billion in carer support, provided each year by the Australian Government and by State and Territory governments through joint programs with the Commonwealth.
The delivery of Australian Government funded community care services, including NRCP, is currently the subject of reform following the completion of a major review. In 2002, the then Minister for Ageing initiated a review of Health's 17 community care programs. The Minister released the resulting report, A New Strategy for Community Care—The Way Forward, on 3 August 2004. This report proposed significant changes to the way in which community care services, including NRCP, are delivered. These changes are intended to provide consumers with easier access to care and support, a fairer system, comprehensive services, and greater consistency in the quality of care. It is in this context that Health has advised that it is working to streamline and improve administrative arrangements for NRCP in association with administrative reform in other community care programs. Implementation of reforms may involve consultation with industry and/or State and Territory governments where appropriate, pilot testing and evaluation prior to full implementation. Health is already well advanced on some initiatives stemming from the review.
The audit objective was to assess the effectiveness of Health's administration of NRCP. The audit comments on a range of issues, including program design, planning on the basis of need, funding, coordination, performance monitoring, and compliance management. It also takes into account Community Care Review initiatives.
Audit objective and methodology
The objective of the audit was to assess the effectiveness of Health's administration of the National Respite for Carers Program.
The audit assessed the effectiveness of Health's administration of NRCP against the following criteria:
- does Health effectively plan Program delivery;
- has Health established appropriate systems/processes to guide Program administration; and
- does Health effectively monitor Program delivery?
To form an opinion against the audit objective, the ANAO interviewed Health personnel, examined Health documents, interviewed personnel at a selection of service providers and stakeholders, and reviewed relevant literature.
Designing the program
NRCP has a number of parts, with different administrative practices for each part.
The design of NRCP reflects the influences of a series of policy initiatives that have shaped the Program since its inception in 1996. These initiatives have created separate components and targeted services within them. As a consequence, NRCP has a number of components, each with its own administration team, guidelines, model of service delivery and reporting processes. This structure, while aligned to the Government's policies, poses challenges for administration and increases costs.
The target groups established by Health for each component of NRCP are consistent with government policy, with the department advising that work is underway to improve guidance to Respite Centres on the targeting of resources.
The target groups for NRCP are based on the policy initiatives that have shaped the Program and the adaptation by Health of the target groups from the Home and Community Care Program (HACC).4 While Health has established target groups for each major component of NRCP and communicated these to funded organisations, it is yet to develop sufficient guidance for Respite Centres, and to a lesser extent Resource Centres, to inform the allocation of services to the different types of recipients within target groups. This guidance is particularly important for programs like NRCP that were designed to complement a range of other programs. It is also an important approach to limit potential cost shifting between programs, departments and different levels of government. Health has advised that refinements to performance targets, once complete, will provide greater assistance to Respite Centres in the allocation of resources.
While Health does not currently have a common assessment tool for NRCP, the department has commenced work to develop one.
A consistently applied assessment tool is an important element in the equitable delivery of services under national programs. Health is yet to establish a common assessment tool to determine eligibility for NRCP services. Differences in assessment practices for NRCP have led to access and equity issues for carers. Health has, however, identified common assessment as a key initiative stemming from the Community Care Review and has commenced work on development of an NRCP assessment tool.
Health has adopted multiple service delivery approaches for NRCP, with some approaches posing administrative challenges.
Health's adoption of flexible service delivery approaches under NRCP facilitates the achievement of policy objectives, supports a carer focus, and is strongly supported by service providers. However, it is more administratively challenging than other approaches. Health has acknowledged these challenges and is working to limit their impact.
Planning program delivery
Health's planning requires further strengthening to support the current size and complexity of the Program.
Health has not developed a strategic plan for NRCP to guide the deployment of resources. The development of a plan of this type would assist Health to integrate the various components within the Program and guide development and expansion. It would also facilitate the establishment of a set of NRCP performance measures against which the performance of the Program could be assessed.
Health has not implemented a methodology to inform its targeting of NRCP services to areas of greatest need.
The absence of an effective needs-based planning approach for NRCP, incorporating service delivery data from other community care programs, has limited Health's ability to target funding to areas of greatest carer need. The assessment of need is an important element of sound program planning. It allows funding providers to target the provision of respite services. It also provides baseline information against which the impact of programs can later be assessed.
While Health has not established a comprehensive set of performance measures for NRCP, it is working to improve performance information.
Health's use of performance information to inform Program delivery and future expansion is limited. This is partly due to the complexity involved in developing performance information of sufficient detail and appropriate coverage. The performance information that Health has established for the Program is not sufficiently integrated, nor does it support the effective monitoring of Program performance. Health is, however, working to improve the quality, quantity and appropriateness of performance information for NRCP.
Administering the program
There is an absence of documented policies and procedures on Health's funding approaches.
Health has not documented administrative procedures or guidelines governing the allocation of funding under NRCP. In addition, the department has not documented a funding formula or funding methodology. The absence of procedures, methodologies and formulae makes it difficult for Health to explain its funding decisions.
Health's approach to the planning of its funding rounds has resulted in timing issues for the release of funds and the conduct of funding rounds.
There are timing issues for funding rounds with NRCP moneys often allocated and required to be committed late in the financial year. Increased service delivery at the end of the financial year can build carer expectations that cannot be met once funding levels return to normal. Further, Health does not have a documented approach to the monitoring of its funding rounds. In particular, Health does not analyse information that would allow it to determine the appropriateness of the time allowed for each phase of its funding rounds. Therefore, it is not in a position to inform future funding activities or to advise the Government of the optimal time required to implement policy initiatives.
Short-term agreements have created uncertainty for service providers and an increased workload for Health administrators.
Health has issued a series of short-term funding agreements to streamline its existing agreements and allow for the introduction of revised contractual terms stemming from the Community Care Review. These short-term agreements have created uncertainty for providers and increased the workload for Health's administrators. Health is working, however, to address this issue, with the implementation of new three-year agreements for funded organisations from 1 July 2005.
Health's administrative practices for NRCP are not nationally consistent.
The absence of an up-to-date NRCP policy and procedures manual has resulted in inconsistent administrative practices between Health's State/Territory Offices (STOs) as well as less efficient, reactive management. While Health has recognised the need for a Program procedures manual, and commenced preliminary work, an up-to-date manual was not in place at the time of audit. Health does, however, hold regular program manager meetings, at which NRCP administrative practices are discussed.
Coordination between NRCP and other community care administrators is limited.
There is insufficient communication and coordination between NRCP and other community care programs. As a consequence, the exchange of planning and service delivery information between programs is limited and is not a routine part of administration. While NRCP program officers are aware of other community care programs, they generally have a limited understanding of the services being provided and their impact on NRCP. This hinders the identification of gaps and inequities in, and duplication of, service delivery. This issue is discussed in The Way Forward, with proposed initiatives aimed at creating a simple, streamlined, responsive and better coordinated community care system.
Administrative resources for Health's smaller programs, including NRCP, are allocated across several programs.
Health allocates its limited administrative resources across its programs on the basis of size and risk. As such, NRCP as one of Health's smaller programs, shares administrative resources with a number of other programs. In meeting the competing resource demands of these programs, NRCP program officers have rationalised their NRCP activities.
The effectiveness of Health's records management practices is limited.
Health's records management practices require strengthening to more effectively support the department's demonstration of due process and to support decision-making within the Program.
Monitoring program performance
Health requires extensive reporting from funded organisations, although limited detail and breadth of reported information lessens its usefulness.
Health has established comprehensive NRCP reporting processes for funded organisations so that it can manage the Program soundly and to ensure accountability for public funds. However, the monitoring system does not provide balanced information to inform Health of the extent to which NRCP is meeting its objectives. For example, Health does not seek carers' and care recipients' comments on the quality and appropriateness of service provision. As well, monitoring systems do not provide Health with sufficient information to enable it to determine whether funded organisations are complying with funding agreements, including compliance with the required National Service Standards. These Standards are important safeguards for people receiving respite services.
Program monitoring is based primarily on self-reporting, with limited verification of information provided in reports.
Health's monitoring system relies primarily on self-reporting, with limited activity from the department to verify the accuracy or quality of information within these reports. The number and frequency of reports also place a considerable workload on Health administrators and funded organisations.
There are problems with the quality of data provided by funded organisations and the way in which this data has been interpreted by Health.
The accuracy of data provided to Health by NRCP funded organisations is affected by confusion in some organisations over important data principles, such as the definition of some terms. Further, the way in which Health has interpreted service delivery data has the potential to distort the level of service delivery reported under NRCP. Health has sought to improve its interpretation of NRCP data through recent guidance to its officers.
Health is introducing a quality monitoring system for NRCP.
Health is working to improve the coverage of its monitoring regime through implementation of a system to better monitor the quality of services provided to carers under NRCP. Health envisages that the system will comprise a three-step process, involving services self-reporting against uniform quality standards every three years and Health officers carrying out a desk audit and a validation visit.
Overall audit opinion
While Health's administration of NRCP supports the delivery of respite, information and counselling services to carers, opportunities exist for Health to improve the effectiveness of its administrative practices.
The significance of weaknesses in administrative practices has increased as the Program has grown in size and complexity. This growth has been primarily driven by government policy initiatives, with complexity arising from the creation of separate components within NRCP. Notwithstanding, the ANAO considers that Health should adopt a more structured, integrated and planned approach to implementation and future expansion of NRCP.
Health has acknowledged problems with the administration and delivery of community care services in general, and more specifically its administration of NRCP. It is currently working to resolve a number of these problems.
The Minister's review of community care services, which resulted in the publication in 2004 of a report entitled A New Strategy for Community Care—The Way Forward, has identified a number of areas where a more consistent and coordinated approach across all of Health's community care programs, including NRCP, is necessary. Health has already commenced the implementation of review initiatives and is well advanced with some.
The ANAO made six recommendations aimed at improving Health's administration of NRCP.
Health advised the following overall comment on the audit:
The Department is supportive of the audit report and agrees to the recommendations. The Department welcomes the ANAO's acknowledgement of the reforms and initiatives already in hand that will address many of the matters raised in the audit report.
In addition, Health provided a response to each of the recommendations. The relevant responses appear immediately following each recommendation, in the body of the report.
1 Australian Bureau of Statistics, 2004 Disability, Ageing and Carers: Summary of Findings, 2004, Canberra, p.3. The Australian Bureau of Statistics defines disability as any limitation, restriction or impairment, which has lasted, or is likely to last, for at least six months and restricts everyday activities. Examples range from hearing loss which requires the use of a hearing aid, to difficulty dressing due to arthritis, to advanced dementia requiring constant help and supervision.
2 Respite care is defined as an alternative or supplementary care arrangement with the primary purpose of giving the carer:
- a short-term break from the usual caring role; and/or
- assistance with the performance of the caring role.
3 The amount of funds allocated across the three major Program components is less than the annual
budget because some funding announced in the 2005–06 Budget, which is included in the annual NRCP
budget, is yet to be allocated to components.
4 Australian Government and State and Territory governments jointly fund community care services through HACC, with State and Territory governments setting priorities for funding across their jurisdictions. Services include delivered meals, home help, respite, personal care, gardening, home modification and transport.