Will the Hostel Survive? R.B. Lefroy

Department of Public Health, University of Western Australia

Submerged beneath the financial furore created by the Residential Aged Care Structural Reform Package is another proposal - unification of hostel and nursing home into a single system. It is claimed that more accurate assessment has eroded the distinction between residents of the two facilities and that “the populations in hostels and nursing homes overlap more than ever before”[l]. That such an overlap exists is not questioned, but the extent shown in the Commonwealth Department of Health and Family Services’ report [Z] does not appear to justify the argument for a single residential system. Moreover, although classification scales help to indicate the desirable manner of care, they do not provide a full description of needs and abilities, particularly regarding the mentally competent resident. It will be difficult to maintain the valuable attributes of the hostel - the design and the more home-like ambience, including privacy - and thereby to encourage a pattern of life as near normal as possible, when the more competent residents are required to share the environment with those who are severely disabled and whose dependency includes deterioration in mental state. Ellen Newton [3] gave eloquent testament to a situation which still remains a concern to residents.

More then 30 years ago, about the same time that Townsend recommended that the large custodial institution should be replaced by the ‘supported residence’ [4], geriatric assessment in Australia focused on the need for a facility which would support elderly people who could no longer live in the community in a reasonable manner but who did not need nursing. Having become a valuable part of residential care, the existence of the hostel is now threatened.

‘Ageing in place’ is given as a reason for condoning - indeed encouraging - unification of the two facilities. As well as being a habit practised by elderly people in the normal community since time immemorial, this was the misguided hope of the original architects of the Aged Persons’ Homes Act who failed to recognise the need for adequate support. The phrase is now resurrected to describe the situation in a hostel when a resident exceeds the limit of care and requires nursing. Instead of the resident being transferred, nursing is to be brought into the hostel. For such a practice to be economical it must involve not one but a number of residents; the distinction between the overall care in the two facilities will thereby be eroded, even though a difference in dependency level and potential function of residents will remain. It is, therefore, not a feasible proposition that the resident who requires nursing should remain ‘in place’. Agencies responsible for hostels should recognise the likelihood that some residents will require nursing attention in the future by planning this provision in a separate (nursing) place.

A further proposal refers to the exclusion of subsidy for residents receiving the minimum care level (hostel care). The care of the person who is no longer socially competent, whose behaviour may be eccentric but who has neither dementia nor advanced physical disability, has been a valuable

Correspondence to Richard B. Lefroy, Department of Public Health, University of Western Australia, Clifton Street Building, Nedlands Campus, WA 6907. Email: lefroy@dph.uwa.edu.au

function of the standard hostel. It should not be allowed to disappear.

Part of the reason for developing a new single Resident Classification Scale is to correct the deficiency in subsidising people with dementia. It has been made clear that the latter will not be achieved by an increase in total subsidy but by weighting behavioural changes relatively higher than others. However, an increase in recurrent funding in the absence of another necessary change, namely, separation (segregation) of people with dementia from the mentally competent, is unlikely to prove effective with regard to the overall problem of dementia care.

Most nursing homes and hostels attempt to care for people with dementia in standard (integrated) facilities; or they might set aside a small section of the building in order to separate residents with behavioural problems. But unless these residents are attended by staff trained in dementia care and who are able to devise a program appropriate to the particular needs of people with dementia, the problem will not be solved. Economy of staff employment demands a resident group larger than the comparatively small number presently constituting the ‘special’ dementia section of a hostel. A separate (segregated) Special Dementia Unit (SDU) in the form of a hostel for 30 or 40 selected residents is required. It is also necessary to have an increase in the number of carers in order to provide appropriate support for people with cognitive impairment and behavioural abnormalities. Unfortunately, the Commonwealth Government has failed to recognise the need for this policy of segregated care. Satisfactory development of the SDU is unlikely to occur in a system which encourages unification of hostel and nursing home.

SUMMARY Specialisation has been a consistent trend since

the custodial institution was abandoned in favour of nursing homes and hostels. Recent proposals, however, no longer support the hostel as a separate entity; nor is there support for the special feature of segregation necessary for the care of people with dementia. The process of specialisation is thereby being reversed.

Townsend supported his proposal by arguing that “we belong to a society that has the means and a greater inclination to act more tolerantly towards victims of adversity?’”41. Can we make a similar claim 30 years later?

REFERENCES 1. Halton J. Resident classification: the development of the

new single Resident Classification System and the Technical Reference Group. National Healthcam 1996; August:21 .

2. Commonwealth Department of Health and Family Services: Aged & Community Care Division. Development of a single instrument for the classification of nursing home and hostel residents. University of Western Australia: Aged Care Research and Evaluation Unit, 1997; 2:l-7.

3. Newton E. This bed my centre. Melbourne: McPhee Gribble, 1979.

4. Townsend P. The last refuge: a study of residential institutions and homes for the aged in England and Wales. London: Routledge and Kegan Paul, 1962.

56 Australasian Journal on Ageing, 17 (2) May 1998