Victorian Auditor-General's Report 
15 August 2012 

Carer Support Programs 
Audit summary
A carer is someone who cares for a relative, partner or friend on an unpaid, informal basis. Carers enable many people to remain living in their homes and communities. This also reduces the financial burden on the health and human services systems. In 2010, Carers Australia estimated that informal carers provided $40.9 billion in care services nationally. In Victoria, there are over 700 000 informal carers, including 194 000 ‘primary carers’, providing support to someone for most of their daily living activities.
While carers contribute greatly to our community, they often do so at an emotional, physical and financial cost to themselves. Carers tend to have poorer health and wellbeing than their non-carer peers and can experience high levels of stress, anxiety and depression as a result of their care responsibilities. Younger carers and those of working age may miss educational or employment opportunities that then affect their ability to participate fully in the community. 
Victorians will rely more heavily on informal care from family and friends in the coming decades. The population is ageing, and the prevalence of physical and mental illness is also on the rise. In addition, State and Commonwealth health and welfare policies continue the shift from institution-based services to community care, in recognition of the benefits of enabling people to stay in their own homes. 
Given these challenges, carers need support to maintain their care role, and recognition for the contribution they make. The role of carers is an integral component to the efficient and effective operation of the health and human services systems. Supporting the sustainability and capacity of carers to maintain their role is therefore core business for system managers and service providers.
The Department of Health and the Department of Human Services fund a range of programs to support primary carers. The following departmental program areas provide and manage carer supports:
·	the ageing and aged care and palliative care program areas in the Wellbeing, Integrated Care and Ageing division of the Department of Health
·	the mental health program area in the Mental Health, Drugs and Regions division of the Department of Health
·	the disability program area in the Disability Services division of the Department of Human Services
·	the child protection program area in the Children, Youth and Families division of the Department of Human Services.
This audit examined whether the departments are effectively recognising and supporting carers.

Conclusions
The departments recognise carers as important stakeholders in the health and human services systems and the programs they manage. This is evident through the range of supports made available to carers. The departments and service providers also recognise the care relationship. They include and consider carers in policy and program development, and involve them in decision-making with the people they care for. 
The departments recognise that supporting carers is core business. However, they do not treat their carer support programs with the rigour core business warrants. This is evident in gaps in data collection, the failure to assess carer needs, and a lack of outcome measurement. Greater rigour around carer support programs is essential to the ongoing development and improvement of these services. Effective carer supports are particularly important, as the departments’ focus on supporting their clients to remain in their homes and communities is reliant on carers. 
Carers experience barriers to accessing supports, such as poor awareness of services and difficulty navigating service systems. The departments’ lack of referral processes, needs assessments, and prioritisation practices for carers across each of the program areas contributes to this. The department and service providers do not identify many carers who may benefit from support services. Inconsistent practices also raise the risk of inequity, particularly for carers trying to access high-demand services.
Despite clear program objectives, such as reduced stress or improved family functioning, the effectiveness of carer support programs is unknown. The departments do not monitor support programs against outcomes for carers and so cannot demonstrate effectiveness. This is a significant gap given the need for effective programs to support the growing community reliance on carers.
Findings
Accessing supports
The departments fund a range of carer support programs, such as counselling, respite and training. However, many eligible carers can miss out because there is limited awareness of available supports, and lack of assessment and referral processes. 
Awareness of supports
Carers frequently reported to this audit that they lack awareness of the available supports. It is also a common finding of departmental evaluations of carer supports. This is despite demonstrated efforts by the departments and service providers to promote carer support programs, for example through print and web media and community expos or events. The departments have yet to attempt to understand what is not working and address the problem.
Carer identification and referral
The departments and their funded service providers do not consistently assess, either directly or by referral, the needs of carers they interact with to identify and provide assistance to those who may need and want support. It is therefore likely that some carers in need are missing out. 
All program areas have systems in place to identify and record the existence of a carer. Three of the five audited program areas have guidance to prompt staff and service providers to assess carer need, or refer them for assessment and support:
·	The Home and Community Care service, in the ageing and aged care program, has a standard tool to assess carer need.
·	The palliative care program adopts national assessment tools for its service providers to use on a voluntary basis.
·	The standard kinship carer assessment tool prompts the child protection worker to consider the carer's needs and whether they would benefit from a referral to a support service. 
However, service providers and departmental staff do not consistently or reliably use the tools in palliative care and child protection.
Consultation with 12 service providers across the five program areas found there was no consistent use of a standardised tool for assessing carer needs. Better identification of carer needs, through referral and assessment processes, would facilitate carer access to supports. This information would also provide the departments with a more complete understanding of their carer population. 
Equity of access
Departmental staff and service providers are prioritising carer access to supports differently, and in some cases, subjectively. Consistent prioritisation of carer need is necessary to assure equity and timely access to high-demand services for those in greatest need.
Brokerage funds provide carers with responsive and flexible financial support including assistance to purchase services or one-off material items. The departments are not adequately oversighting brokerage funds for carers, or providing enough guidance to the service providers distributing these funds. Variable practices are evident, such as different funding rules between service providers who are administering the same fund, unexplained variations in average amounts paid by service providers, and a lack of independent processes which allows the same staff to make and approve applications. These inconsistencies raise the risk of inequity for carers.
Timeliness of access 
Wait time data is one indicator of the service system’s ability to cope with demand. It can provide useful information to departments and service providers for service planning and development work. However, the departments and service providers do not routinely collect wait time data, which means that timeliness of access to carer supports is unknown. 
Anecdotal wait times reported by consulted service providers indicate variable performance within and across program areas. Wait times are measured for one carer support only—case management in disability. Wait times for this service vary from just over a week to 12 weeks across geographical areas. Such variation makes it difficult for carers to have any expectation of how long they may wait for a support.
Experience of supports
The departments and service providers are effective in recognising carers and the care role in policy and program development and delivery. However, they cannot clearly demonstrate the effectiveness of carer support programs.
Carer recognition
There is clear departmental policy guidance to program areas and their funded service providers that states they must recognise the role of carers in their service delivery. Departments and service providers have demonstrated a commitment to realising this policy. Across the audited program areas, the audit found many examples of:
·	the involvement of carers in program, policy and service development
·	the involvement of carers in planning processes with the person they care for
·	the inclusion of carer-related standards in quality assurance regimes.
Carers report varied experiences of recognition by the departments and service providers. Many carers we consulted related good experiences where they felt recognised. Some carers, for example, those caring for people with mental health issues, felt that awareness of their role has been increasing over the past decade. However, all had examples where this had not occurred, and in particular, where their needs as individuals were not always considered. These experiences indicate the ongoing need for effort to embed a culture of carer recognition in service provision. 
Effectiveness of supports
The departments are not monitoring outcomes against program objectives to demonstrate the effectiveness of carer supports. Objectives of carer support programs include reducing carer stress, sustaining the care relationship, or improving family functioning. However, consultation with service providers revealed only isolated, ad hoc use of carer-related outcome measurement tools.
The departments have undertaken one-off evaluations of most carer support programs. However, these provide only limited assurance of effectiveness. Often evaluations do not address the objectives of the program, review only a narrow part of a service, and cannot determine effectiveness due to a lack of data on carer-related outcomes. 
Recommendations
Number	Recommendation	Page	
	That the Department of Health and the Department of Human Services:		
1.	identify and address gaps in the promotion of carer supports to improve carer awareness of services	15	
2.	require consistent carer identification and needs assessment	15	
3.	improve administration and monitoring of carer brokerage funds	15	
4.	monitor and report on timeliness of access to carer supports	15	
5.	develop outcome measures for carer supports and monitor outcomes.	26	

Submissions and comments received
In addition to progressive engagement during the course of the audit, in accordance with section 16(3) of the Audit Act 1994 a copy of this report was provided to the Department of Health and the Department of Human Services with a request for submissions or comments.
Agency views have been considered in reaching our audit conclusions and are represented to the extent relevant and warranted in preparing this report. Their full section 16(3) submissions and comments however, are included in Appendix A.