Pearls and Irritations

The sector that includes some of our most vulnerable citizens was unprepared for the end of lockdowns: the Commonwealth is overwhelmingly to blame.

It seems incredible that aged care is again on the frontline of the COVID-19 pandemic, with outbreaks in about half of aged care homes in Australia. This is despite overwhelming evidence that people in aged care are among our most vulnerable citizens. Of all the sectors that should have been prepared for the end of lockdown, it was this one.

There are 2700 aged care homes in Australia and they are the responsibility of the Commonwealth government, with states and territories sharing this only to the extent that they are responsible for public health protection on the ground.

The first major COVID-19 outbreaks occurred in aged care in 2020 in NSW, initially at Dorothy Henderson Lodge in Sydney and then at Newmarch in Sydney. By the time the virus had run its course at Newmarch, 19 residents had died and a further 37 residents and 34 staff had been infected. At the end of the first wave, 61 aged care residents in NSW were infected and 29 had died, a mortality rate of 48 per cent.

This was soon followed by major outbreaks in aged care homes in Victoria. By the end of 2020, 224 homes across Australia had experienced an outbreak, 2238 residents had been infected and 678 residents had died. Most of these were in Victoria. The case fatality rate was 30 per cent. The aged care royal commission held a special hearing in 2020 into what had gone wrong and we were not alone in analysing what had happened.

Covid and aged care: When you are in a deep hole, the most important thing to do is stop digging.

While there were differences in the details of the different outbreaks, two overwhelming conclusions can be drawn from the experiences leading up to the current Omicron wave. The first is that, even after allowing for differences in size and location, better staffed public sector homes did demonstrably better. Residents in private-for-profit homes, with fewer and less qualified staff, fared much worse.

The second conclusion is that most of the responsibility rests with the Commonwealth. It did not adequately prepare itself or the aged care sector. Planning was deficient and the outbreaks were inadequately managed.

More importantly, systemic problems that had existed in aged care for at least a decade – funding, workforce and governance – resulted in the sector being in crisis even before the pandemic, providing a ripe environment for the tragedy that unfolded.

This background provides an important context for the current Omicron wave spreading through the aged care sector. By the end of 2020, residential aged care represented 75 per cent of all Covid deaths in Australia and it was clear that residents were the most vulnerable of our population. There were also deaths among people receiving aged care at home, although the picture there is murkier because of inadequate information collection.

The (failing) aged care system we have in 2020 operates exactly as it was designed to – Part 1

Vaccination rollout

In January 2021 the government announced a Covid vaccine national rollout strategy. Aged care residents and staff were identified as first priority populations and included in stage 1a. The goal was for all those in that stage to be vaccinated by the end of April, with second doses available 12 weeks later.

But, like the rest of the rollout, the aged care vaccination program was eventually implemented several months behind schedule. This then delayed the booster program, which did not begin until November 8, 2021. On Christmas Eve, the government reduced the interval between doses to four months. But by then the Omicron outbreak had taken hold.

Omicron

The appointment of a new NSW premier in October 2021 heralded a major change in the management of the pandemic that then flowed on to the rest of Australia. The new roadmap implemented over October and into November lifted almost all restrictions including face mask and social gathering requirements.

The current Omicron variant emerged in November and it has spread like wildfire both in the general community and aged care. Its spread was accelerated by the recent easing of restrictions, most of which were not reinstated even as the virus spread at a record rate.

From just 39 outbreaks at the end of September, there are, as of last week, 1107 active outbreaks in residential aged care facilities nationally — 425 in NSW, 356 in Victoria, 155 in South Australia, 133 in Queensland, 22 in Tasmania, 15 in the ACT and one in the Northern Territory. In total, 3208 residents and 3806 staff have been infected. This takes the total number of aged care residents infected with COVID since the pandemic began to more than 9000, with 1072 deaths — a 12 per cent fatality rate. The case fatality rate for the general community stands at 0.2 per cent. Aged care residents make up 0.7 per cent of the population and 0.6 per cent of Covid cases, yet they represent 38 per cent of all Covid deaths so far.

The (failing) aged care system we have in 2020 operates exactly as it was designed to – Part 1

What went wrong this time?

In addition to the ongoing systemic failures in aged care, four specific issues have exacerbated the breadth and depth of the current outbreaks in aged care.

1: Government decisions on lockdowns and restrictions: NSW was the first jurisdiction to announce a revised roadmap out of lockdowns and restrictions in the leadup to Christmas 2021. This was soon followed by similar announcements in other jurisdictions as well as the opening up of domestic and international borders.

The timing of these various roadmaps was driven by the percentage of the eligible population who were vaccinated. This failed to take into account whether systems and resources were in place to deal with the inevitable surge in cases in the aged care sector. A similar observation could be made about the health and disability care sectors.

In the case of aged care, the sector was not ready when the states and territories opened their borders and eased restrictions. This no doubt reflects the lack of coordination between the Commonwealth, responsible for aged care, and states and territories, responsible for managing the pandemic on the ground.

2: The vaccination program in aged care: While Health Minister Greg Hunt has been in the media recently stating that the vaccination booster program is ahead of schedule, it came too late for aged care homes. Residents needed to have their booster vaccinations before lockdowns and restrictions were lifted, not afterwards. Only about three-quarters of homes have been visited for booster delivery so far. The arrival of the Omicron variant exacerbated this problem.

The other major limitation is the design of the booster program itself. Each home is visited only once with vaccines offered to those who are there on the day. Residents who are not eligible on the day, are unwell or are not in the home simply miss out. Homes are then responsible for organising vaccination for them on a case-by-case basis.

It really is not adequate to offer vaccines on a one-off basis. This is particularly the case in a sector that has considerable resident turnover. The aged care sector has around 180,000 beds and about 240,000 people moving through those beds in any one year. With such a turnover, aged care needs a regular program of visits, not one-off events.

3: Access to rapid antigen tests: One of the real tragedies of the pandemic has been the social isolation of aged care residents. The first response to an outbreak has been to lock families out and lock residents in. This is despite the fact that most outbreaks have begun with staff, not visitor, infections.

Easy access to rapid antigen tests (RATs) is a critical part of protecting residents and staff and is key to being able to open homes up to visitors. But this is still not happening. There is no concept of prevention. Homes are only provided with RATs after they have an outbreak, not before. And even then, the supply they receive is inadequate, apparently calculated on the basis of one test every three days for staff and visitors. The Commonwealth does not officially provide RATs for residents as testing is classified as public health and is thus a state responsibility. Inevitably access to RATs for residents differs between jurisdictions and depends on availability.

4: Access to adequate and affordable PPE: Aged care homes are receiving some equipment from the national stockpile but are required to purchase other items themselves. The financial costs to homes can be considerable, exacerbating financial pressures in the sector. This is not financially sustainable in the longer term.

Bigger issues

At its heart, the systemic problem in aged care is the lack of governance. The early waves of the pandemic saw considerable debate on where the responsibility for our vulnerable older citizens lies. The Commonwealth’s perspective was that responsibility lay with aged care providers. However, the capacity of providers to deliver the support needed by residents is fundamentally dependent on the policy parameters and resourcing that the government provides.

As the royal commission revealed, there has been a long-held agenda within government to curtail the anticipated costs associated with an ageing population, in particular aged care. This has been addressed explicitly by introducing higher fees and charges for services and routinely failing to increase funding to the sector along with the consumer price index, as well as implicitly through expanding the number of private-for-profit providers under the ideological and rather naive assumption that this will increase competition and drive efficiencies.

Aged care homes: the weakest COVID-19 link

This has resulted in a significant shift in the staffing profile of those providing care to our most vulnerable citizens, with experienced clinicians such as registered nurses being replaced by less costly and less experienced personal care workers. The outcome has been that over half of aged care homes have unacceptable staffing levels, measured against international benchmarks.

This mindset of the Commonwealth in having a “hands-off” approach to aged care also explains the lag in response times at each step of the pandemic: getting access to PPE, addressing workforce challenges, providing advice on visitors, rolling out vaccinations and, most recently, providing RATs for staff, residents and visitors. It is not as if the Department of Health is unaware of the challenges facing the sector – it is simply that it does not consider it needs to take a leadership role in responding.

This is not surprising as the current crisis again reflects the reactive and iterative policymaking that has characterised aged care in recent decades. And as long as responsibility for aged care remains at the national level, this is unlikely to change. As numerous commentators have highlighted on this website and elsewhere, there has been a significant hollowing out of the public service over time, with an increasing reliance on politicians’ staffers and external contractors for policy advice that invariably focuses on the political objectives of government rather than the broader needs of the public.

This has severely constrained the ability of the bureaucracy to understand, let alone deal with, the complexities within the aged care sector. Addressing the challenges resulting from Covid requires sophisticated thinking, not just more of the same iterative, reactive policy adjustments. The question is: can the machinery of our government develop the capacity to do this?