Pearls and Irritations

The starting point for a fit-for-purpose, 21st-century aged care system is public recognition that we can no longer continue to simply subcontract out our public duty of care for frail and vulnerable people. Older Australians deserve so much better.

The first major Covid-19 outbreaks occurred in aged care in NSW, initially at Dorothy Henderson Lodge in Sydney and then at Newmarch in Sydney. By the time Covid-19 had run its course at Newmarch, 19 residents had died and a further 37 residents and 34 staff members 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%.

The recent Royal Commission hearing rightly focused on the experience and lessons from NSW rather than the tragedy still unfolding in Victoria. The last thing the people fighting the pandemic in Victoria need right now is to be distracted from their task by being required at a Royal Commission. But what people in Victoria did need was the lessons learned in NSW. They didn’t get them beforehand.

The enormity of the tragedy in aged care in Victoria still unfolding reflects the bigger picture there. By 15 August, a total of 16,517 people in Victoria have contracted Covid-19 and 293 have died. 20% of all active cases relate to aged care. The aged care cases include over 1,300 residents and more than 700 staff and close contacts. With 176 resident deaths so far, Victorian aged care represents two thirds of all deaths in Victoria and 48% of all deaths nationally.

By 14 August, about 12% of aged care homes in Victoria have had a Covid-19 outbreak. The rate varies from 2% of homes managed by the state government to about 17% of homes managed by private-for-profit providers. Even after allowing for differences in size and location, the better staffed public sector homes have done demonstrably better. Residents in private-for-profit homes, with fewer and less qualified staff, have fared worst.

According to data on the Victorian health department website, the Covid-19 rate in private homes in Victoria is 40 times higher than in public homes. They reported six cases out of 5,400 beds in state government-operated residential aged care and 1,923 cases out of 44,600 beds in privately run aged care. However, the public homes are more concentrated in rural areas and this needs to be taken into account when interpreting these numbers.

The active aged care outbreaks with the highest cumulative case numbers as at 14 August are as follows:

•  203 cases linked to Epping Gardens Aged Care in Epping (private for profit)
•  187 cases linked to St Basil’s Homes for the Aged in Fawkner (private not for profit)
•  154 cases linked to Estia Aged Care Facility in Ardeer (private for profit)
•  130 cases linked to Kirkbrae Presbyterian Homes in Kilsyth (private not for profit)
•  123 cases linked to BaptCare Wyndham Lodge Community in Werribee (private not for profit)
•  108 cases linked to Outlook Gardens Aged Care Facility in Dandenong North (private not for profit)
•  101 cases linked to Estia Aged Care Facility in Heidelberg (private for profit)
•  91 cases linked to Twin Parks Aged Care in Reservoir (private for profit)
•  90 cases linked to Arcare Aged Care Facility in Craigieburn (private for profit)
•  83 cases linked to Glendale Aged Care Facility in Werribee (private for profit)

So, what are the lessons on what has gone so seriously wrong? The first relates to prevention. The evidence is that Covid-19 is entering homes via aged care staff, not families. Staff education in infection control is essential as is making sure homes have all the PPE they need. Both have been inadequate. Homes have been expected to buy their own PPE and have only been getting access to the national stockpile after an outbreak has already occurred. There are many staff infected as well as residents and some homes have ended up with no staff at all with many infected and others in isolation.

The evidence in Victoria has revealed a pattern of casual low paid insecure personal care and domestic workers employed in multiple facilities being infected with Covid-19 and taking it from one home to another. Paid pandemic leave for casual insecure workers should have been in place from the onset. Homes should have been employing more full time staff and less casual and insecure workers and the Commonwealth should have required this at the onset. It finally directed this in August.

The second lesson relates to preparation. The Commonwealth should have accepted responsibility to arrange with states and territories an on-site risk assessment of every home including a stocktake of PPE and an agreed escalation plan for how to manage the first case/s. This needed to involve public health (infectious diseases and aged care nurses) working collaboratively with aged care homes to help them prepare. Preparation should also have included a plan for how families might participate as partners in care. This needed to differentiate between general visitors and immediate family who are willing to be trained in how to use PPE and who are prepared to spend blocks of time (not casual visits) in the home in the event of a Covid outbreak. There is no evidence that locking families out makes a home safer. There is good evidence that loneliness, isolation and depression are already rife in aged care. Covid-19 has only made that worse.

The third lesson is about the management of the first case/s. The evidence is now compelling from both NSW and Victoria that the first case/s need to be managed very fast and very assertively. South Australia was the first state to decide to always move the first cases out in order to protect the other residents and staff. Other states need to adopt a similar approach. Every state (including NSW and Victoria) has more than adequate hospital beds to manage the initial cases. They do not have enough beds in the event of major outbreaks in large homes.

The final set of lessons relate to management of a full outbreak once it occurs. We now have homes in Victoria that have gone from only one or two cases to 100 cases in less than 10 days, including homes with 100% of staff in isolation. Planning to manage the situation on a case by case basis and without clear Commonwealth State agreements in place is a recipe for disaster as the Newmarch experience illustrated.

The one thing we know for sure is that a major outbreak cannot be managed in any congregate living situation (be it a cruise ship, an aged care home or a boarding school) unless it is possible to completely separate positive and negative cases and have separate physical spaces and staff for each group. This is extremely difficult in homes with shared bedrooms and in open plan homes with people with dementia who are prone to wander. But it is essential. If that cannot be guaranteed, either the positive or negative cases need to be moved out. A Covid-19 outbreak in an aged care home is about meeting the clinical needs of infected individuals at the same time as protecting everyone else.

A key issue examined and hotly contested at the Royal Commission hearing was whether or not there was an aged care Covid-19 plan, with the Commonwealth witnesses adamant that a plan was in place. But surely that assessment missed the point. If there was a plan, it clearly did not work in NSW and it is not working in Victoria.

While many people at all levels are working hard to manage the Covid-19 pandemic in aged care, the fundamental problem is that they are working in a system that is not fit for purpose. Our aged care system is broken and needs rebuilding from the bottom up. The starting point for a fit-for-purpose, 21st-century aged care system is public recognition that we can no longer continue to simply subcontract out our public duty of care for frail and vulnerable people. Older Australians deserve so much better.

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