Covid and aged care: When you are in a deep hole, the most important thing to do is stop digging.Jun 7, 2021
The bottom line is that the needs of older people cannot be met unless aged care is better integrated with hospitals and health care managed by states and territories.
The Australian Government is 100% responsible for aged care. This includes both the governance and funding of a diverse range of services spread across Australia including both residential aged care homes and aged care at home. Both residential and home aged care have been in a mess for years, so much so that the current government commissioned a Royal Commission into its quality and safety. Its final report, running to thousands of pages, was delivered in February 2021. Our earlier articles provide a commentary on the Royal Commission and the government response.
An earlier article in 2020 outlined the structural and systemic factors that were contributing to the COVID disaster then emerging in residential aged care. It concluded that ‘at the heart of the issues are key questions about the role of aged care, the role of the market and the interface between aged care and health care’. These issues remain at the heart of the current failure to vaccinate the aged care sector.
By the end of the second COVID wave to hit Australia, only 225 people living in the community had died in Australia. This was a remarkable achievement. Yet aged care was a different story. While aged care residents represent less than 1% of the Australian population, they were in the front line of the COVID pandemic in 2020. By the end of 2020, COVID had spread into around 150 aged care homes and 685 aged care residents had died. By the end of the year, aged care accounted for 75% of all Australian deaths due to COVID-19.
The Aged Care Royal Commission held a special hearing on COVID during 2020 and its findings were scathing. It concluded that the Commonwealth had failed in its duty of care to ensure that, once COVID entered an aged care home, the homes had the systems in place to minimise spread and protect residents. The Department of the Health and the government rejected the Commission’s assessment. From their perspective, they had managed COVID in aged care homes well and they seemed genuinely perplexed that others did not share that view.
Twelve months on, the same deep failings in the governance and delivery of aged care are the cause of the current failure of the aged care COVID vaccination program. As Rick Morton rightly observed on the ABC The Drum “Because they couldn’t bring themselves to admit anything went wrong, they haven’t done anything to change the behaviours that might’ve allowed them to get the vaccine program right now.” The first step in fixing a problem is recognising you have a problem.
The fateful decision
By the second half of 2020 it was apparent that a COVID vaccine might be available to vaccinate the population in 2021. At that point the Commonwealth started planning the vaccine roll-out. By November 2020, the government was signing vaccination supply agreements with various companies with the Prime Minister proclaiming that:
“There are no guarantees that these vaccines will prove successful, however our Strategy puts Australia at the front of the queue, if our medical experts give the vaccines the green light.”
At some time during that planning period, the Commonwealth made a fateful decision about aged care. It had two options. It could decide that the Commonwealth alone would take responsibility for vaccinating the staff and the people living in residential aged and disability care. If so, they would deliver the vaccine program by contracting with private providers. Alternatively, they could enter into agreements with the states and territories to take responsibility for the roll-out program. If so, the states and territories would deliver the vaccine program via their local health services working with GPs. The Commonwealth decided to go it alone.
Implementation challenges and failures
This decision set the aged care (and disability care) vaccination program up to fail before it had even started. From that point on it was just a matter of time. Under Australia’s federation arrangements, the states and territories are the level of government with the infrastructure and expertise to deliver human services across the whole of Australia. They have literally decades of experience of delivering complex public health and personal care services via local health networks and hospitals.
The Commonwealth lacked the experience and the infrastructure and it has showed. There are 2,700 aged care homes spread across Australia and ensuring that every resident and every staff member was offered a timely vaccination was always going to be an enormous challenge.
Residential aged care residents and workers were included in Phase 1a of the COVID-19 vaccination rollout, expected to commence in mid-February 2021 and completed within ‘approximately’ six weeks (joint media release from Minister for Health and Minister for Aged Care Services). But things have not gone according to plan.
There are obvious logistical challenges in supplying vaccine in the right quantities at the right time at 2,700 aged care homes across Australia and in ensuring that the team doing the vaccinations is coordinated with the team supplying the vaccine. In addition, a significant proportion of aged care residents cannot give their own consent because of dementia or significant frailty. It was left to homes to organise next of kin consent, sometimes with only a day or two of notice.
In the event, using private organisations for vaccine distribution in aged care has been really hit-and-miss. Essentially the Commonwealth engaged labour-hire companies that did not necessarily have any experience working with the sector or working with frail older people. One hundred and ten days on, barely two-thirds of residents are fully vaccinated (two doses) to protect against the latest COVID strain.
This is not good enough but it is hardly surprising. The Commonwealth has really struggled with the aged care rollout because it does not have a history or track record in implementing services or experience in widespread distribution of vaccines. This is what the states do – and they have the systems, infrastructure and expertise to do it well.
Yet again, the Commonwealth seems genuinely perplexed that there is so much criticism of the roll out in aged care. Based on their appearance at the recent May 2021 Senate Estimates hearing, they seem to feel aggrieved and at a loss to understand what all the fuss is about.
The vaccination of aged care staff
The challenges in vaccinating aged care staff as well as residents would have become more complex after problems with one of the vaccines emerged which meant it could not be given to staff under 50. In the event, this has not been a problem. Somewhere along the way, a decision was made that the Commonwealth would abandon its plan to accept responsibility for staff. The contracts it let for vaccine administration only covered residents.
The current estimate is that about 10% of aged care staff have been vaccinated. In truth, there is no way of knowing what percentage of staff are fully vaccinated. The Commonwealth does not know either the numerator or the denominator. It does not know how many aged care staff are employed because there are no requirements on homes to report their workforce profile and the only information currently available is an Aged Care Workforce Census conducted for two weeks every four years. That problem will not be solved until October 2022. It does not know how many staff have been vaccinated as it has no systems in place to collect the required information. There are plans to establish an information portal but participation will be voluntary.
Structural failings making it worse
The structural failings in the aged care system that underpinned the tragedy of 685 COVID deaths in 2020 have not been addressed. Our work for the Royal Commission showed how poorly staff levels were, compared to international standards. Fast forward to 2021 and only 40% of residents are in aged care homes with adequate staffing levels. 60% are in homes without sufficient staffing to ensure good and consistent infection control. The government has announced the introduction of mandated staff ratios and minimal standards for registered nurse coverage but these changes will only be introduced late 2022. Until then, it is business as usual.
The other major structural failure continues to be over-reliance on casual workers and labour hire companies. As the Victorian experience of 2020 demonstrated, a major factor in transmissions was staff working in multiple homes. Numerous staff were infected in one home and, unknowingly, then proceeded to take COVID with them from one home to another. Aged care homes were also the source of multiple infections back out in the community as aged care workers passed the virus onto their families. Infection does not just run one way.
At the peak of the pandemic in July 2020, the government prohibited casual staff employment arrangements that allowed staff to be employed across multiple facilities. But single-site employment requirements only lasted until November 2020 when the (voluntary) guidelines were updated. Aged care homes can now be run again by casual workers who have precarious employment arrangements in multiple facilities. These staff are very poorly paid and have no choice but to accept work wherever they can find it.
The future of aged care
The Commonwealth is 100% responsible for aged care. It is time to question whether the Commonwealth is the right tier of government to manage aged care into the future.
The Royal Commission made the case for change and recommended what some have called an ambitious reform agenda. The COVID vaccination rollout to date is evidence that little has changed. While the government has indicated its willingness to throw money at aged care, it is clear that it does not have the appetite to drive transformational change.
The Commonwealth seems intent on running aged care as a silo in isolation from the other services that older people need. Yet this is the direct opposite to what is actually required. People do not need aged care because they are old. People need aged care because they develop chronic and complex health conditions that limit their ability to live independently. The bottom line is that the needs of older people cannot be met unless aged care is better integrated with hospitals and health care managed by states and territories.
The vaccine rollout is further evidence that, even in a pandemic, the Commonwealth is unwilling or unable to drive and lead the better integration of aged care and health care. Given this, it may be time to transfer aged care back to the states and territories where aged care can be integrated with their subacute health and community services and where the quality and safety of aged care can be better assured.