We need more than an Auditor-General’s report on COVID-19 vaccination

Aug 24, 2022
Vials of the COVID-19 vaccine
Image: Wikimedia Commons

The recent Auditor-General’s report on the COVID-19 vaccine rollout gave the Department of Health a C-minus – late starting work, not paying close attention to the curriculum, but scrambling to catch up and deliver an adequate but not wholly satisfactory performance. However, the aged care vaccine rollout raises a fundamental issue outside the scope of the audit.

Although performance audits carried out by the Auditor-General extend to “a review or examination of any aspect of the operations of the person or body”, the ANAO eschews reviews of policy processes. Performance audits focus on Departments’ performance in implementing the policy of government.

Junior ANAO staff sometimes seek to stray into policy considerations, and I once had to tell a zealous young auditor that the Department of Health could not be held responsible for the content of a multilateral Commonwealth-State agreement signed by First Ministers. However, successive Auditors-General have realised that canvassing the merits of the policy design underpinning programs is best left to the political process.

One of the many vexed aspects of the vaccine rollout was the provision of vaccine to people in residential aged care. Residents were included in Phase 1a of the rollout, which began on 22 February 2021, and was marked by the then Prime Minister receiving his first vaccination together with an aged care resident the previous day.

Then Minister Greg Hunt said in a 16 February 2021 media release that
“priority is being given to residential aged care facility staff and residents. The vaccination program will begin in every state and territory and will include regional and rural aged care facilities. It is anticipated that the roll out to aged care facilities will take approximately six weeks [i.e., by end April]”.

However, progress was much slower than planned, and on 20 April 2021 the Department of Health pushed back the completion date to May. The Audit report found that it was not until June that “second dose vaccine clinics for… residents were completed for 99 per cent of [aged care facilities]”. This high rate of facility coverage did not result in an equally high rate of resident coverage: by 10 January 2022 13 per cent of residents had still not received two doses of a COVID-19 vaccine, even though by then they were eligible for a third dose.

The Government had decided in late 2020 that vaccinations in residential aged care were to be provided by contracted “in-reach” services: teams of health workers who travelled to residential facilities to provide vaccinations. Following a tender process, two companies (Healthcare Australia and Aspen Medical) were selected to provide services when the rollout started.

The Audit report identified a number of reasons for the slow rollout in residential care:
• There were delays in scheduling visits to [residential care] sites. Health’s reporting showed the VAS [Vaccine Administration Services] providers it contracted had difficulty scheduling visits and engaging with facilities, which caused confusion and uncertainty at some facilities.
• The Vaccine Administration System used by Health to order and register vaccinations required manual processes that caused delays and errors in the data.
• Health contracted a limited workforce of the VAS providers (which were also contracted to deliver the residential disability rollout).
• One VAS provider contracted by Health early in the rollout underperformed. This poor performance included governance and logistics issues resulting in cancellations of clinics at short notice.

While the Department of Health did its best to play catch-up by contracting additional providers and enlisting Primary Health Networks, it is hard to disagree with Professor Stephen Duckett’s conclusion in a recent article in the International Journal of Environmental Research and Public Health that “the rollout of vaccinations to residential aged care and disability facilities was a slow-moving tragedy”.

In line with the Auditor-General’s approach of not going behind policy decisions, the Audit report accepts the Government’s decision to use “in-reach” services for residential aged care as a given. However, this decision should be examined as part of any overall review of Australia’s pandemic response.

On the face of it vaccinating aged care residents should be a relatively simple task. As Nick Cave sang, “we know who you are, and we know where you live”. Residents are usually taking at least one medication (and often many more), meaning that they and the service where they live has an established on-going relationship with a local pharmacy. While not all services have a registered nurse available 24 hours a day every day, they generally have a RN available on the day shift on weekdays who could administer vaccinations.

A system using this existing infrastructure would have had to manage the unique cold chain requirements applying to the Pfizer vaccine. However, the subsequent availability of Pfizer through community pharmacy demonstrates that this could be achieved.

But rather than use the existing channels the Government decided to use external providers with no relationship with aged care services (other than as a source of contract labour to some) and with no regional presence. And these providers also had to deal with the cold chain issue.

In his 16 February 2021 media release Minister Hunt stated that the residential aged care COVID vaccination process was “expected to draw from the extensive experience in delivering influenza vaccines to aged care residents”. If influenza vaccines were delivered to aged care residents by centrally contracted flying squads this experience would have been very useful – but they aren’t.

Some commentators have suggested that the decision to contract out the task was a conspiracy to channel money to particular companies linked to government. I don’t believe this for a moment.

In Professor Duckett’s recent article he concludes that
“another strategic mistake was to emphasise a privatised Commonwealth-distribution strategy through GPs and pharmacists rather than embrace state distribution through mass vaccination hubs. Again, this appears to have been a politically-driven, credit-claiming choice that created logistical challenges”.

I think the decision to use outsourced providers for residential aged care may well have been another “credit-claiming choice” – albeit one that delivered very little credit.

The COVID-19 pandemic has demonstrated how vulnerable people in residential aged care are to pandemic illness. It is important that the health system learns from this experience to design better systems and processes for dealing with the next pandemic – or even a widespread community outbreak of a transmissible illness.

Part of that preparation should be consideration of how best to vaccinate the residential aged care population, and development of a plan for how to do it based on the best available advice and evidence. That requires a review of the policies that were adopted to deal with the pandemic – not to allocate responsibility or blame, but to discover what worked and what did not. That is far beyond the scope of the ANAO.

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