RESIDENTIAL AND SUPPORT SERVICES FOR OLDER PEOPLE IN THE WAIKATO, 1992-1997: PRIVATISATION AND EMERGING RESISTANCE.

• Author: Joseph, Alun E.

INTRODUCTION

The "experiment" in neo-liberal structural adjustment (Kelsey 1997) that began with the election of a reform-minded Labour government in 1984 has touched virtually every aspect of New Zealand life and reached into every corner of the country (Britton et al. 1992, Le Heron and Pawson 1996). One of the hallmarks of the adjustment process has been the unevenness of impacts (Moran 1999); some population groups have been affected more by economic and social restructuring than others (Kelsey 1997), as have some regions and localities (Le Heron and Pawson 1996). In this paper, we focus on older people as a group affected by economic and social restructuring, and relate their experience to the explicit views expressed by the state since 1984. It is arguable that older people are much more sensitive to changes in social policy than are the great majority of younger New Zealanders. This sensitivity amounts to virtual "dependency" for many in the areas of income support and age-targeted accommodation and caring services (Saville-Smith 1993). Older people, as disproportionate users of services, are also affected by shifts in policy on health care and social support in general (Richmond et al. 1995).

We use a case study of the Waikato to anchor a commentary on the implications for older people of shifts in policy on the provision of residential and caring services. In earlier work, we analysed the impacts of changes in the provision of residential care on the evolving geography of population ageing in the region (Joseph and Chalmers 1996); assessed the implications of service-sector restructuring for the in-place experience of ageing (Joseph and Chalmers 1995); and presented "insider" views of what it means to be old in a service-depleted community (Chalmers and Joseph 1998). Through this research, we developed an appreciation of the implications for older people of the "first wave" of economic and social restructuring that swept over the region between 1984 and 1992. We turn here to the "second wave" of restructuring, which we consider to be prefigured by a series of critiques within government of the health care system, beginning in earnest in 1991 (Barnett and Barnett 1997). We seek to identify the reactions of older people to changes in housing and service availability, which we see as constituting an evolving "politics of resistance" to social policy change.

The remainder of the paper is organised in three major sections. The first of these reviews the evolution of pervasive and complex relationships between social policy and the lives of older people. The year 1984 is used to divide the review of developments in the welfare state into "historical" and "contemporary" components. Assessments of the implications of shifts in social welfare policy are then moderated against an awareness of the changing needs of older people and of the capacity of their families and communities to respond to demands for assistance. The second section presents the methods and results of the Waikato case study, with interpretation of the latter organised around the emergent themes of privatisation and resistance. In a concluding section, we place the main arguments into their wider, national context, emphasising implications for social policy.

SOCIAL POLICY AND THE WORLDS OF OLDER PEOPLE

In this section we summarise the history of support for older New Zealanders in the century prior to 1984, and assess the impact of these changes.

Building the Welfare State: 1885 to 1984

The main streams of social support for older people in New Zealand society can be traced to two pieces of nineteenth century legislation. The Hospital and Charitable Institutions Act of 1885 was a significant step in the medicalisation of ageing (Saville-Smith 1993). The local boards set up to provide hospital and charitable relief under the Act initially distinguished systematically between financial assistance related to indigence ("outdoor relief") and residential care provided because of illness ("indoor relief"). However, boards later adopted residential solutions to both problems. The impetus for institutionalisation was strengthened further by the Old Age Pensions Act of 1898. The Act provided income support for older people, thereby further reducing the apparent need for hospital boards to sponsor outdoor relief (Saville-Smith 1993).

The establishment of a statutory age for commencement of retirement pensions over the next half century ensured the growing dependence of older New Zealanders on pensions as a source of income. Contemporaneously, the widespread adoption and acceptance of medical filters for determining access to social support in the home, such as assistance with housework, and (significantly) qualification for special accommodation, reinforced the association of ageing and disability.

The four decades following 1945 witnessed a growing complexity in social policy. For older people, the state began to withdraw from direct provision of services (Saville-Smith 1993). In 1951 religious and welfare organisations became eligible for subsidies to build accommodation for older people. The year 1961 saw the establishment of the Rest Home Subsidy Scheme in Auckland. The aim of this programme was to free up public hospital beds occupied by older, long-term patients through support for private rest home providers. The level of the private financial contribution from older people was determined by the Department of Social Security. This programme was introduced progressively in New Zealand from 1966.

By 1970 a complex range of "partnerships" between hospital boards and a range of religious and welfare organisations had emerged. While hospital boards continued to take responsibility for medicalised care for the "older old", they also worked with the voluntary sector in responding to growing needs for care in the community, with various domestic assistance schemes and meals-on-wheels programmes that had first emerged in the 1950s (Saville-Smith 1993). The 1950s and 1960s also saw the increasing use of the social security special assistance provisions to enable older people to meet the cost of essential services subject to user pay regimes such as home help and private rest home services.

In the 1970s, and particularly the 1980s, the private, for-profit sector became a growing provider of residential care services, although the important principle of subsidising patients in private geriatric hospitals via the budgets of hospital boards had been established years earlier in the Social Security Act of 1938 (Joseph and Flynn 1988). The now-defunct Geriatric Hospital Special Assistance Scheme (GHSAS) was the mechanism for directing public funds to private geriatric hospitals run by religious and welfare organisations and commercial operators. Geriatric long-stay beds in public hospitals were available (at no charge other than loss of pension) in some board areas, albeit subject to waiting lists. In others, older people and their families turned to private hospitals, with access to subsidies from the GHSAS subject to income testing (Joseph and Flynn 1988). The financial attractions for area health boards of subcontracting geriatric hospital care to private hospitals were such that the supply of long-term geriatric beds in private hospitals increased by 258% between 1978 and 1984 (Saville-Smith 1993:90). In contrast, the number of licensed (private) old peoples' homes increased by a more modest 35% between 1981 and 1985, rising from 410 to 522 (Social Monitoring Group 1987:73).

Restructuring the Welfare State: 1984-1997

The retreat from state provision of services (as against funding) to older people was already well underway in 1984 (Kelsey 1997). We have emphasised the recruitment of the voluntary sector (in the 1950s and 1960s) and private sector (in the 1970s and early 1980s) as partners in the provision of residential care, but the state had also demonstrated ambivalence in the area of income support. From the early 1950s on, relative to the average wage, there was an erosion of the level of financial support to retired people, and much experimentation with targeting mechanisms, second-tier provisions and superannuation contribution plans (St. John 1993). After 1984, the retreat from state provision of services continued and the private sector became identified as the "provider of choice" within an increasingly complex system.

In the area of residential care, the 1987 review of rest home subsidy saw religious and welfare rest homes being brought into line with private rest homes and forgoing their salary subsidy and access to capital subsidies for buildings, in place of a fee for service for financially eligible residents. The extension of the rest home subsidy scheme to all parts of New Zealand provided opportunities for private providers to offer...