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Systems of aged care in Melbourne
SYSTEMS
OF AGED
CARE
IN MELBOURNE
ANNA L. HOWE Geography
Department,
Monash Umversrty. Austraha
Abstract-To assess the proposals that community care for the aged can provtde an alternattve to instttutional care, patterns of utihzatton of several community servtces have been analysed and a largescale survey made of nursmg homes in Melbourne. Fmdmgs of that survey are outhned here, with discusston of the provtsion of nursing home beds, patterns of admtssion and pattent characteristtcs. It IS suggested that a more diverstfied approach m planning nursing home proviston, and more flexible use of nursmg home beds. are needed if mstttutional care IS to functton so as to complement commumty services.
COMMUNITY
CARE OR INSTlTUTlONALlSATlON?
In recent years the development an alternative
to institutional
of community care as care has been adopted
in Australian government policy. albeit more in word than action [I]. Particular concern has arisen because of the very high provision of nursing home beds, the national average in 1973 being 45 per 1000 persons aged 65 years and over. Although comparisons with other nations face some definitional difficulties, figures for the United States, Sweden, and the United Kingdom have been stated as 45, 36 and 17 per 1000 respectively [2]. The imbalance between community services and institutional care is most clearly seen in relative expenditure in each area. some $40m going to the former and $265m to the latter in 1976-77 [3]. Shifts in resource allocation should aim to enable a larger number of aged people to benefit from some assistance; it is also thought that the type of care would in many cases be more appropriate. In an attempt to establish an initial pattern of demand for care, the distribution of Melbourne’s aged population was analysed [4]. Recognising that not all aged people have the same need for support, investigation was also made of factors which predispose some aged to the risk of losing their independence. Census data on a range of physical and social characteristics of the aged population, by Local Government Areas. were used in a factor analysis which yielded one major factor, labelled “social risk”. The “social risk” factor scores were taken as an indicator of need. It was next hypothesized that areas where the aged population showed a high level of “social risk” would exhibit high rates of utilisation of community services and generate high rates of admission to institutional care. Correlation analysis of “social risk” factor scores and utilisation rates for six community services (e.g. domiciliary nursing, home help) showed the relationships to be weak or non-existent, and a zero correlation was found for the “social risk” index and nursing home admissions. From an examination of community services it was apparent that the organisational structure of a service affected its responsiveness to need. Advantages were found for those services which were orgamsed regionally rather than locally; services which were delivered to the home also met need more satisfactorily than those which ‘37
required the client to attend a central service outlet, especially if transport was not provided. Investigations to date have concluded that the provision of community services in Melbourne bears little relationship to need, and falls far short of an integrated system. with few Local Government Areas having even the rudiments of co-ordinated community care 151. ACCESS TO NURSING
HOME CARE
The mismatches between the level of need and the utilisation of community services identified in many areas indicate a very unequal pattern of access to community care. In turning attention to access to institutional care for the aged, the standard geographical approaches to access to health services are largely inappropriate. Those approaches aim to measure the relationships between frequency of use, travel time or distance, and the distribution of facilities. However, physical proximity has little relevance where admission usually occurs only once, and the trip involved may be a one-way one at that. Further, it cannot be assumed either that the aged have access to local nursing home beds, or that they are always admitted directly from their place of usual domestic residence. Access to nursing home care thus cannot be summarized in bed/population ratios for specific areas. Even if a standard expressed by such a ratio were reached in all areas, it could not readily be interpreted to mean that equality of access had been achieved. Because of the complex paths of admission, and frequent transfers between different domestic and nursing home locations, a first step must be the clarification of the origins and destinations of patients, and of intervening moves made in their admission paths. As it was necessary to carry out a large scale survey to obtain this data. additional information was collected at the same time. The patient census form and the overall survey design were adapted from a survey carried out in New South Wales in 1976. [6] and the results will enable comparisons to be made between the states. Survey forms were sent to 216 nursing homes in the Melbourne metropolitan area m December 1978. with a follow-up round in February 1979. Some 57”, of all nursing homes responded, accounting for over 66”, of the total 7856 beds. The
ANNA
13x
response rate was representative wtth regard to the various types of nursing homes (private. voluntary organisation and public) and their geographical distribution. and provides a reliable basis for comparison of different patient populations. Detailed analysis is still underway, and full results will be presented elsewhere [7]. The remaining discussion raises some of the issues ‘to be considered in reporting the findings. PROVISION
OF NURSlNG
HOMES
Victoria has a lower provision of nursing home beds than some other Australian states, the rate being 31.5 per 1000 aged persons in 1973 compared to 62.0 per 1000 in New South Wales. However, there has been an expansion of 349; over the last decade. the total number of beds reaching 10,870 in 1977-78; the great majority of these, some 7900, are in the Melbourne metropolitan area. Much of the difference between the States, in terms of the number of beds and relative importance of public, private and voluntary organisation provision, can be explained by the separate legislation relating to the establishment of nursing homes and regulating their operation in the past. With an increasing role being played by the Commonwealth Government, an attempt has been made to make provisions more uniform, although no rationale for such uniformity has ever been established. A standard of 50 beds per 1000 aged, the average of provisions in 1973, has been adopted nationally. While limiting expansion in states exceeding this standard, the effect in states below this standard has been a rapid expansion in bed numbers. A major fault of such a simple ratio is that, in its calculation, no account is @ken of the availability of alternative forms of supportive accommodation, nor of any differences in patients occupying the beds in each state. For example, some 167; of all nursing home patients in New South Wales were former psychiatric patients, whereas only 1% of Victorian patients were admitted from mental hospitals. In Melbourne, many former psychiatric patients are accommodated in registered boarding houses. known as Special Accommodation Houses, which also provide for the frail aged who are not in need of nursing care. The level of nursing care given in nursing homes was classified as “extensive” for almost 80:/, of Victorian patients, but for only 36% of those in New South Wales, where the majority were classified as receiving “ordinary” nursing care. This difference is most significant in cost terms as the two levels of nursing care attract differential rates of subsidy, a high proportion of which is met directly by the Commonwealth. Data showing that Victorian patients are older, and more likely to have been admitted from another institution rather than directly from their domestic home may be interpreted as evidence of the need for “extensive” care. The approach to provision of nursing home beds by application of a standard has been widely criticised. Comprehensive information on nursing homes and their patients is an initial requirement in developing a more discriminating planning approach, which recognizes the diversity of patients and may lead to more varied solutions. At the central government level in particular, the uniform policy needs to be
L.
HOWE
modified to take mto account the reasons for present variations found between the states. and their rmphcattons for future development. AD,MlSSION P.ATTERNS
At the mtra-metropolitan scale. varratlons are found between local areas in both the provtslon of nursing home beds and the rates of admission from the aged populatton. As has been noted. admission rates do not reflect the risk level of the aged population. and areas of high provtston and high admtsston rates tend to coincide m the higher socio-economtc status areas, notably the older eastern and southern suburbs of Melbourne. Patients from these areas also “overtlow” to other areas, thus exacerbating then already lower provision for the local population. While the location of beds and admtssion could not be managed at the local scale, some degree of regional self-containment is warranted; present attempts to balance the provision of nursing home beds across the metropolitan regions will achieve little unless there is also some regulation of admission to them. Regionahsation is already emerging with five State Geriatric Centres each designed to serve a defined region. The Centres have also established links with specific acute hospitals from which they receive patients. Similar associations have developed on an informal basis between some hospitals and other nursing homes. Preliminary analysis shows that almost as many patients were admitted from acute hospitals, 309,,, as from their domestic home, 36’;; moves from another nursing home accounted for a further 149;. The volume of movement involved is indicated by the finding that in 709; of cases. the local area of the patient’s usual domestic residence differed from that of their present nursing home place. Detailed analysis of patterns of admission and transfer is expected to show considerable variation between different types of nursing homes and between regions, and by documenting these patterns the survey aims to provide a basis for modelling a regional system. PATIENT CHARACTERISTICS
A brief demographic profile of patients can be drawn with age, sex and marital status as the central variables. Only 7:,; of all patients were below the age of 60 years, while 61”; were aged 80 years or over. Greater female longevity is reflected in some 68 percent of females being in this latter age group, compared to 3996 of male patients. These older women make up just over half the total patient population. and overall women outnumber men by a ratio of 3.3 to 1. Marttal status is closely related to age-sex distnbution; widows accounted for 50’:, of all patients, whereas only 8% were widowers. The never married, 209; of all patients, were far over-represented compared to the non-instituttonalised population. These demographic patterns confirm the observation made in another Australian study, that marriage acts as a significant protection against institutionalisation in old age, expecially for older men with younger wives [S]. Such conjugal support is however givenlittlerecognitioninsupportprogrammes,although the informal care of this kind can be most important
239
Systems of aged care in Melbourne
when examining the role of communtty services in supporting the aged at home. The nature of care required and effectiveness of services provided frequently depends as much on the social support available to give ongoing care as on the physical condition of the patient. Demographic and social data obtained in the survey will be related to the diagnosis and disabilities of patients in further investigations. Analysis of data on disabilities and treatment is to focus on two areas. First is the degree of disability resulting from different conditions, and the associated prospects for rehabilitation. The provision of occupational therapy, physiotherapy and other rehabilitative treatment is extremely limited in most nursing homes, but the expansion of these treatment areas in the Geriatric Centres is resulting in a growing number of patients being discharged mto the community. A higher turnover achieved through using even a small number of beds specifically for rehabilitation has a considerable potential in making more effective use of resources. Rather than simply aiming to provide more beds, plannmg needs to give attention to how beds are used. More flexibility in the management of beds, including short stay beds for those normally maintained in the community, could do much to relieve the “placement problems” and reduce pressure for ever more beds. The second consideration follows from the first, as the development of rehabilitation appears to be hampered by the mix of patients now found in most nursing homes. Identification of special groups with particular disabilities and treatment needs could lead to some specialisation. One readily identified group is the young disabled, many of whom are paraplegics or quadraplegics and require very different care to those aged suffering from, for example, senile dementia. There are few nursing homes catering to such specific groups, and here again there is a need for a more diversified approach to planning so that specialist facilities can be developed with appropriate staff instead of simply providing more numerous but undifferentiated beds. ALTERNATIVE
OR COMPLEMENTARY
SYSTEMS OF CARE?
Through diversifying the planning of nursing home development, community care will come to be seen as complementary to institutional care, not an alternative to it. In providing care for the aged in need, the question becomes not a choice between these two systems, but the selection of certain elements from a wide range of supportive services. Many of these are however not currently available in Melbourne, and even where several services may operate, they are rarely
linked in an integrated way. As a result, when the need for any form of care arises, some aged have no choice but to resort to a nursing home bed; those who can afford it may purchase such care even though the support provided may well be beyond their actual needs. Others are left to struggle with inadequate domiciliary services until a crisis comes upon them. At whatever point care is sought, careful assessment is required to ensure that the most appropriate type and level of supports are applied to each patient’s circumstances. The Geriatric Centres are increasingly performing this function of evaluating need and drawing on community services, nursing homes and other providers of sheltered accommodation, but for the majority of the aged the allocation of supportive resources seems largely a matter of chance. There is very little understanding of how individuals enter different systems of care, and subsequently pass through them. From the analysis of the aggregate spatial patterns of the utilisation of different types of care, it is hoped the research described here may point the way for behavioural studies into these aspects.
REFERENCES
1. For relevant policy statements, see Seaman K. (Chairman). Care of the Aged. Social Welfare Commission, Canberra, 1975; and Holmes A. S. (Chairman). Reporr of the Commirree on Care of the Aged and the Infirm. Aust. Govt. Publ. Service, Canberra, 1977. 2. Figures quoted in Health Commission of N.S.W. A Study of Nursing Homes in New South Wales. The Commission, 1977. For a comparative discussion of the place of nursing homes in care of the aged, see Brocklehurst J. C., Geriatric Care in Advanced Socreties. M.T.P., Lancaster, 1975. 3. Holmes A. S., op. cit., pp. 16-17. 4. Howe A. L. The changing distribution of Melbourne’s aged population: Patterns and implications. Aust. geogr. Stud. 16, 136, 1979.
5. For a full account of these studies, see Howe A. L. Identifying the aged in need: a social indicators approach; and Organisation and utilisation of community services in-Melbourne. In Towards an OIder Australia (Edited bv Howe A. L.). Universitv of Queensland Press, Brisbane, forthcoming. 6. Health Commission of New South Wales. op. cit. 7. A report on the findings is to be prepared as a Working Paper in Geography, Department of Geography, Monash University, by December 1979. 8. This conclusion is stated in a survey of the aged in the Australian Capital Territory, reported in Ford B. The community-who are the aged? Proc. Aust. Assoc. Gerontol. 1, 203, 1972; and discussed more generally in Ford B. The Elderly Australian, pp. 56-57. Penguin, Ringwood, 1979.
OF AGED
CARE
IN MELBOURNE
ANNA L. HOWE Geography
Department,
Monash Umversrty. Austraha
Abstract-To assess the proposals that community care for the aged can provtde an alternattve to instttutional care, patterns of utihzatton of several community servtces have been analysed and a largescale survey made of nursmg homes in Melbourne. Fmdmgs of that survey are outhned here, with discusston of the provtsion of nursing home beds, patterns of admtssion and pattent characteristtcs. It IS suggested that a more diverstfied approach m planning nursing home proviston, and more flexible use of nursmg home beds. are needed if mstttutional care IS to functton so as to complement commumty services.
COMMUNITY
CARE OR INSTlTUTlONALlSATlON?
In recent years the development an alternative
to institutional
of community care as care has been adopted
in Australian government policy. albeit more in word than action [I]. Particular concern has arisen because of the very high provision of nursing home beds, the national average in 1973 being 45 per 1000 persons aged 65 years and over. Although comparisons with other nations face some definitional difficulties, figures for the United States, Sweden, and the United Kingdom have been stated as 45, 36 and 17 per 1000 respectively [2]. The imbalance between community services and institutional care is most clearly seen in relative expenditure in each area. some $40m going to the former and $265m to the latter in 1976-77 [3]. Shifts in resource allocation should aim to enable a larger number of aged people to benefit from some assistance; it is also thought that the type of care would in many cases be more appropriate. In an attempt to establish an initial pattern of demand for care, the distribution of Melbourne’s aged population was analysed [4]. Recognising that not all aged people have the same need for support, investigation was also made of factors which predispose some aged to the risk of losing their independence. Census data on a range of physical and social characteristics of the aged population, by Local Government Areas. were used in a factor analysis which yielded one major factor, labelled “social risk”. The “social risk” factor scores were taken as an indicator of need. It was next hypothesized that areas where the aged population showed a high level of “social risk” would exhibit high rates of utilisation of community services and generate high rates of admission to institutional care. Correlation analysis of “social risk” factor scores and utilisation rates for six community services (e.g. domiciliary nursing, home help) showed the relationships to be weak or non-existent, and a zero correlation was found for the “social risk” index and nursing home admissions. From an examination of community services it was apparent that the organisational structure of a service affected its responsiveness to need. Advantages were found for those services which were orgamsed regionally rather than locally; services which were delivered to the home also met need more satisfactorily than those which ‘37
required the client to attend a central service outlet, especially if transport was not provided. Investigations to date have concluded that the provision of community services in Melbourne bears little relationship to need, and falls far short of an integrated system. with few Local Government Areas having even the rudiments of co-ordinated community care 151. ACCESS TO NURSING
HOME CARE
The mismatches between the level of need and the utilisation of community services identified in many areas indicate a very unequal pattern of access to community care. In turning attention to access to institutional care for the aged, the standard geographical approaches to access to health services are largely inappropriate. Those approaches aim to measure the relationships between frequency of use, travel time or distance, and the distribution of facilities. However, physical proximity has little relevance where admission usually occurs only once, and the trip involved may be a one-way one at that. Further, it cannot be assumed either that the aged have access to local nursing home beds, or that they are always admitted directly from their place of usual domestic residence. Access to nursing home care thus cannot be summarized in bed/population ratios for specific areas. Even if a standard expressed by such a ratio were reached in all areas, it could not readily be interpreted to mean that equality of access had been achieved. Because of the complex paths of admission, and frequent transfers between different domestic and nursing home locations, a first step must be the clarification of the origins and destinations of patients, and of intervening moves made in their admission paths. As it was necessary to carry out a large scale survey to obtain this data. additional information was collected at the same time. The patient census form and the overall survey design were adapted from a survey carried out in New South Wales in 1976. [6] and the results will enable comparisons to be made between the states. Survey forms were sent to 216 nursing homes in the Melbourne metropolitan area m December 1978. with a follow-up round in February 1979. Some 57”, of all nursing homes responded, accounting for over 66”, of the total 7856 beds. The
ANNA
13x
response rate was representative wtth regard to the various types of nursing homes (private. voluntary organisation and public) and their geographical distribution. and provides a reliable basis for comparison of different patient populations. Detailed analysis is still underway, and full results will be presented elsewhere [7]. The remaining discussion raises some of the issues ‘to be considered in reporting the findings. PROVISION
OF NURSlNG
HOMES
Victoria has a lower provision of nursing home beds than some other Australian states, the rate being 31.5 per 1000 aged persons in 1973 compared to 62.0 per 1000 in New South Wales. However, there has been an expansion of 349; over the last decade. the total number of beds reaching 10,870 in 1977-78; the great majority of these, some 7900, are in the Melbourne metropolitan area. Much of the difference between the States, in terms of the number of beds and relative importance of public, private and voluntary organisation provision, can be explained by the separate legislation relating to the establishment of nursing homes and regulating their operation in the past. With an increasing role being played by the Commonwealth Government, an attempt has been made to make provisions more uniform, although no rationale for such uniformity has ever been established. A standard of 50 beds per 1000 aged, the average of provisions in 1973, has been adopted nationally. While limiting expansion in states exceeding this standard, the effect in states below this standard has been a rapid expansion in bed numbers. A major fault of such a simple ratio is that, in its calculation, no account is @ken of the availability of alternative forms of supportive accommodation, nor of any differences in patients occupying the beds in each state. For example, some 167; of all nursing home patients in New South Wales were former psychiatric patients, whereas only 1% of Victorian patients were admitted from mental hospitals. In Melbourne, many former psychiatric patients are accommodated in registered boarding houses. known as Special Accommodation Houses, which also provide for the frail aged who are not in need of nursing care. The level of nursing care given in nursing homes was classified as “extensive” for almost 80:/, of Victorian patients, but for only 36% of those in New South Wales, where the majority were classified as receiving “ordinary” nursing care. This difference is most significant in cost terms as the two levels of nursing care attract differential rates of subsidy, a high proportion of which is met directly by the Commonwealth. Data showing that Victorian patients are older, and more likely to have been admitted from another institution rather than directly from their domestic home may be interpreted as evidence of the need for “extensive” care. The approach to provision of nursing home beds by application of a standard has been widely criticised. Comprehensive information on nursing homes and their patients is an initial requirement in developing a more discriminating planning approach, which recognizes the diversity of patients and may lead to more varied solutions. At the central government level in particular, the uniform policy needs to be
L.
HOWE
modified to take mto account the reasons for present variations found between the states. and their rmphcattons for future development. AD,MlSSION P.ATTERNS
At the mtra-metropolitan scale. varratlons are found between local areas in both the provtslon of nursing home beds and the rates of admission from the aged populatton. As has been noted. admission rates do not reflect the risk level of the aged population. and areas of high provtston and high admtsston rates tend to coincide m the higher socio-economtc status areas, notably the older eastern and southern suburbs of Melbourne. Patients from these areas also “overtlow” to other areas, thus exacerbating then already lower provision for the local population. While the location of beds and admtssion could not be managed at the local scale, some degree of regional self-containment is warranted; present attempts to balance the provision of nursing home beds across the metropolitan regions will achieve little unless there is also some regulation of admission to them. Regionahsation is already emerging with five State Geriatric Centres each designed to serve a defined region. The Centres have also established links with specific acute hospitals from which they receive patients. Similar associations have developed on an informal basis between some hospitals and other nursing homes. Preliminary analysis shows that almost as many patients were admitted from acute hospitals, 309,,, as from their domestic home, 36’;; moves from another nursing home accounted for a further 149;. The volume of movement involved is indicated by the finding that in 709; of cases. the local area of the patient’s usual domestic residence differed from that of their present nursing home place. Detailed analysis of patterns of admission and transfer is expected to show considerable variation between different types of nursing homes and between regions, and by documenting these patterns the survey aims to provide a basis for modelling a regional system. PATIENT CHARACTERISTICS
A brief demographic profile of patients can be drawn with age, sex and marital status as the central variables. Only 7:,; of all patients were below the age of 60 years, while 61”; were aged 80 years or over. Greater female longevity is reflected in some 68 percent of females being in this latter age group, compared to 3996 of male patients. These older women make up just over half the total patient population. and overall women outnumber men by a ratio of 3.3 to 1. Marttal status is closely related to age-sex distnbution; widows accounted for 50’:, of all patients, whereas only 8% were widowers. The never married, 209; of all patients, were far over-represented compared to the non-instituttonalised population. These demographic patterns confirm the observation made in another Australian study, that marriage acts as a significant protection against institutionalisation in old age, expecially for older men with younger wives [S]. Such conjugal support is however givenlittlerecognitioninsupportprogrammes,although the informal care of this kind can be most important
239
Systems of aged care in Melbourne
when examining the role of communtty services in supporting the aged at home. The nature of care required and effectiveness of services provided frequently depends as much on the social support available to give ongoing care as on the physical condition of the patient. Demographic and social data obtained in the survey will be related to the diagnosis and disabilities of patients in further investigations. Analysis of data on disabilities and treatment is to focus on two areas. First is the degree of disability resulting from different conditions, and the associated prospects for rehabilitation. The provision of occupational therapy, physiotherapy and other rehabilitative treatment is extremely limited in most nursing homes, but the expansion of these treatment areas in the Geriatric Centres is resulting in a growing number of patients being discharged mto the community. A higher turnover achieved through using even a small number of beds specifically for rehabilitation has a considerable potential in making more effective use of resources. Rather than simply aiming to provide more beds, plannmg needs to give attention to how beds are used. More flexibility in the management of beds, including short stay beds for those normally maintained in the community, could do much to relieve the “placement problems” and reduce pressure for ever more beds. The second consideration follows from the first, as the development of rehabilitation appears to be hampered by the mix of patients now found in most nursing homes. Identification of special groups with particular disabilities and treatment needs could lead to some specialisation. One readily identified group is the young disabled, many of whom are paraplegics or quadraplegics and require very different care to those aged suffering from, for example, senile dementia. There are few nursing homes catering to such specific groups, and here again there is a need for a more diversified approach to planning so that specialist facilities can be developed with appropriate staff instead of simply providing more numerous but undifferentiated beds. ALTERNATIVE
OR COMPLEMENTARY
SYSTEMS OF CARE?
Through diversifying the planning of nursing home development, community care will come to be seen as complementary to institutional care, not an alternative to it. In providing care for the aged in need, the question becomes not a choice between these two systems, but the selection of certain elements from a wide range of supportive services. Many of these are however not currently available in Melbourne, and even where several services may operate, they are rarely
linked in an integrated way. As a result, when the need for any form of care arises, some aged have no choice but to resort to a nursing home bed; those who can afford it may purchase such care even though the support provided may well be beyond their actual needs. Others are left to struggle with inadequate domiciliary services until a crisis comes upon them. At whatever point care is sought, careful assessment is required to ensure that the most appropriate type and level of supports are applied to each patient’s circumstances. The Geriatric Centres are increasingly performing this function of evaluating need and drawing on community services, nursing homes and other providers of sheltered accommodation, but for the majority of the aged the allocation of supportive resources seems largely a matter of chance. There is very little understanding of how individuals enter different systems of care, and subsequently pass through them. From the analysis of the aggregate spatial patterns of the utilisation of different types of care, it is hoped the research described here may point the way for behavioural studies into these aspects.
REFERENCES
1. For relevant policy statements, see Seaman K. (Chairman). Care of the Aged. Social Welfare Commission, Canberra, 1975; and Holmes A. S. (Chairman). Reporr of the Commirree on Care of the Aged and the Infirm. Aust. Govt. Publ. Service, Canberra, 1977. 2. Figures quoted in Health Commission of N.S.W. A Study of Nursing Homes in New South Wales. The Commission, 1977. For a comparative discussion of the place of nursing homes in care of the aged, see Brocklehurst J. C., Geriatric Care in Advanced Socreties. M.T.P., Lancaster, 1975. 3. Holmes A. S., op. cit., pp. 16-17. 4. Howe A. L. The changing distribution of Melbourne’s aged population: Patterns and implications. Aust. geogr. Stud. 16, 136, 1979.
5. For a full account of these studies, see Howe A. L. Identifying the aged in need: a social indicators approach; and Organisation and utilisation of community services in-Melbourne. In Towards an OIder Australia (Edited bv Howe A. L.). Universitv of Queensland Press, Brisbane, forthcoming. 6. Health Commission of New South Wales. op. cit. 7. A report on the findings is to be prepared as a Working Paper in Geography, Department of Geography, Monash University, by December 1979. 8. This conclusion is stated in a survey of the aged in the Australian Capital Territory, reported in Ford B. The community-who are the aged? Proc. Aust. Assoc. Gerontol. 1, 203, 1972; and discussed more generally in Ford B. The Elderly Australian, pp. 56-57. Penguin, Ringwood, 1979.