At 95, Lilian Robinson is blazing a new path for older New Zealanders who want to stay out of rest homes.
Four years ago, after a clot in her lower spine, doctors told her that she would either die, be paralysed from the waist down or end up incontinent.
"I'm none of those things!" she boasts.
Caregivers visit her three times a day to help her shower in the morning, cook an evening meal about 5pm and help her go to bed at about 8pm.
Her two daughters, who both live near her Onehunga home, take her shopping, get her library books and visit every Sunday to do her hair and share her home-made scones.
Eldest daughter Georgina Cook says neighbours in the other flats in Mrs Robinson's sunny four-unit private cul-de-sac "put out her rubbish bin and say hello and that sort of thing".
And with all this help, the former machinist and great-grandmother-of-four lives an independent life.
"They bred us tough in our day. We walked everywhere, there were no motorcars, we worked very hard," she says.
"I have my ironing to do. I always find plenty to do to clean my house and keep it tidy."
Only a few years ago, Mrs Robinson and others like her would have been in a rest home. But New Zealand, where older people are still more likely to die in residential care than in any other country, is belatedly expanding support for elderly people to stay in their own homes - though still in fits and starts.
Numbers in aged residential care have risen only slowly from a low of 28,715 in 2007-08 to 32,000 today. More than twice as many - 75,000, or one in every eight people aged 65 and over - now receive care at home.
A 2010 report by consultants Grant Thornton found that subsidised rest-home bed days as a share of the population fell by about a third in the seven years to 2008, while home support hours for the aged jumped by 56 per cent from 6.5 million hours a year in 2001 to 10.2 million in 2005.
The picture since then is less clear. State funding has more than doubled again since 2004-05 to $269 million in 2012-13, but Health Ministry figures (which differ from Grant Thornton's) show that home-support hours rose by only 45 per cent, from 7.2 million hours in 2004-05 to 10.5 million in 2012-13.
The rest of the extra money has gone into pay rises for support workers in 2005 and 2007, and a shift towards more expensive personal care such as showering while low-paid support for housekeeping has been cut.
Access Homehealth chief executive Graeme Titcombe says the funding rate for every hour of personal care has risen only about 5 per cent in total since 2007, while the minimum wage has gone up 22 per cent from $11.25 to $13.75 an hour.
He says Access home care workers' starting rate has risen in line with the minimum wage, but qualified and experienced caregivers who once earned above the minimum "have come back towards the minimum".
"There has been a cut in skill margins," he says.
Enliven, the Presbyterian Support service which supports Mrs Robinson, says it pays a starting rate of $15.40 thanks to a flexible bulk funding system in the Auckland District Health Board area.
But a North Shore home care worker with 22 years' experience in the Waitemata board area says her pay was cut when the Salvation Army undercut the previous provider to win a home care contract in 2000, and has been static at $14.83 an hour since 2007.
"There will be vast numbers that have not had an increase since 2007, apart from those on the minimum wage," Mr Titcombe says.
Despite the spending increases, the home care budget is still only a fraction of the $928 million public subsidy for residential care.
Home care providers have had to comply with a national standard only since September 1 this year. There are still no minimum training requirements for their workers.
In contrast to disabled people under age 65, who can get 24-hour care with health funding in small homes of three or four clients or with ACC funding in their own homes, there is no funding for 24-hour home care over 65.
"All district health boards have a threshold," explains Home Health Association chief executive Julie Haggie. "Once you tip over that, they fund you for residential care only."
Older people like Mrs Robinson, and others with more intensive needs, can stay in their own homes only if families and other unpaid "natural supports" are available.
But if family members have to stop work to care for elderly parents, they get very little help. They can get a supported living payment, currently $258 a week, and if they need a break they can get about $75 a day towards paying someone else.
"We are quite mean to carers," says Carers NZ chief executive Laurie Hilsgen.
In high-cost housing areas such as Auckland, Age Concern says one of the biggest problems for people reaching old age without owning a home is a severe shortage of affordable rental housing.
Some councils still own pensioner rental flats, built with low-interest state loans over 70 years, but councils have struggled to maintain the flats since the loans ended in the early 1990s. Former Auckland mayor John Banks sold Auckland City's housing to Housing NZ in 2002, and Hamilton sold three pensioner blocks last year.
Age Concern organises volunteers to visit elderly people regularly but is not funded to provide services such as transport, apart from acting as agents for the Total Mobility scheme which pays half of taxi costs for the disabled. Some branches employ home maintenance people to help with small jobs such as changing lightbulbs, but these depend on charitable funding.
Psychiatrist Dr Chris Perkins of the Selwyn Foundation's Centre for Ageing and Spirituality says elderly people deserve the same support to stay in their own homes as disabled people under 65.
She says other countries fund care for older people to live in houses with three to five others as we do for younger disabled people.
Abbeyfield houses are a rare local example, and Anglican-owned Selwyn has just opened a similar home for 11 elderly people in Birkenhead.
Selwyn also runs 32 day centres for the elderly in parishes, but Dr Perkins says they depend on volunteers and more support is needed.
"If people could have their person that needs care go to a day programme every day from 9 to 5, then they (the family carers) could keep going to work," she says.
She says the whole community needs to learn how to look after the confused elderly.
"In Japan they have wardens whose job it is to assist people with dementia," she says. "We need a dementia-friendly community so that when you find someone wandering around who looks lost, you know what to do."
Home finds a woof a day keeps the blues away
One of the most important individuals at Elizabeth Knox Home and Hospital in Auckland is a crossbred Maltese terrier named Jan.
One of Jan's owners, Pat Stanley, 71, has lived at Knox for three years. But her husband, Neil, who brings the dog to visit three days a week, says many residents have adopted her.
"She becomes a point of difference and creates conversation," he says. "When I leave here I'm happy because she has made people happy."
She is not the Epsom home's only animal visitor. In the busy physiotherapy room, a parrot named Whirly perches on Max Pemberton's shoulder as he stands in a contraption that helps him stay upright independently.
Out in the corridor, another dog, Buster, trails after the home's chief executive, Jill Woodward, who brings him in from home. Apparently he co-exists happily with residents' cats.
On the day the Herald visits, sisters Daphne and Frances Brown, aged 98 and 96, feed lambs brought in by the home's hairdresser.
The animals are all part of a new approach to aged care called the Eden Alternative, developed in the United States and adopted by 16 New Zealand homes so far - 15 charitable homes, like Knox, and a small privately owned Waikato home, Lifecare Cambridge.
"You often get an interaction when you put animals in front of people," Ms Woodward explains. "Animals, plants and children are the three elements in the Eden Alternative."
The philosophy holds that most suffering among the elderly stems from feeling lonely, helpless and bored. Close relationships with other people and animals beat loneliness, opportunities to care for others beat helplessness, and unexpected events overcome boredom.
More than 200 volunteers and frequent visits from St Cuthbert's College girls from across the road give the 137 Knox residents plenty of opportunities to chat. Many volunteers are migrants and international students who may need to overcome loneliness just like the residents, and the home has recently won funding to provide volunteer training in NZ language and culture.
The approach also gives elderly people as much control as possible over their own lives.
At Knox that partly means weekly residents' meetings to make decisions such as allowing a visit from the Herald, a residents' committee, and including residents on interview panels to select new staff.
It also means letting frail people take risks.
What our investigation has found:
• Older people are more likely to end up in residential care in NZ than in any other developed country.
• Care providers say they are funded only to provide "a minimum level of care", almost always without full-time physiotherapists or occupational therapists.
• Providers say state funding is $500 million below the level required to justify building a new stand-alone care home.
• Providers are trying to close the gap partly by charging premiums for en suite bathrooms and other services.
• Rest home caregivers earn a median of about $15 an hour, only $1.25 more than the minimum wage.
• Audits released this week show most rest homes are achieving most of the required standards, but there are lapses in care at some homes.
Tomorrow: How to choose the best care
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