For the past week or so, accusations have been flying back and forth about whether a clear national plan has been in place to prevent older people in aged care homes dying from COVID-19.
Dr Brendan Murphy, the secretary of the Department of Health, told the Royal Commission into Aged Care Quality and Safety on Wednesday:
“We reject categorically that the Australian government failed to adequately plan and prepare.”
With more than 200 residents having already died prematurely of Covid-19 in aged care homes (and the number rising every day), it is obvious that the planning and preparation was not effective.
Australia had advanced warning. Evidence from around the world showed the virus spread like wildfire in residential aged care settings. It was clear our aged care sector needed to prepare. The question being asked is: Did the federal government do enough?
Earlier in the week, counsel assisting the royal commission, Mr Rozen QC, asserted that the aged care sector was under-prepared for the pandemic.
“Neither the Commonwealth Department of Health nor the Aged Care Quality and Safety Commission (the regulator) had developed a Covid-19 plan specifically for the aged care sector.”
Dr Nick Coatsworth, Deputy Acting Chief Medical Officer, said this assertion was “frankly insulting”. He strenuously defended the federal response, arguing that sweeping changes to society were introduced to protect older Australians. But “sweeping changes” are not evidence of a specific pandemic plan for residential aged care.
The government has now presented documentary evidence of the plan: The Communicable Diseases Network Australia (CDNA) National Guidelines for the Prevention, Control and Public Health Management of COVID-19 Outbreaks in Residential Care Facilities in Australia.
‘No guarantee’ that information is accurate
Let’s be clear: these are guidelines, not a plan. They contain a disclaimer acknowledging that there is no guarantee that “information in the guideline is accurate, current or complete”. What type of plan is that?
Furthermore, the guidelines state: “Clinical judgment and discretion may be required in the interpretation and application of these guidelines.” Whose clinical judgment? A personal care attendant – the bulk of the workforce in aged care homes – with only a few weeks’ training?
The guidelines acknowledge that elderly residents often have atypical symptoms including behaviour change and may not develop a fever. “Ideally (my italics), staff should know residents well so that they can detect changes in behaviour.”
Clearly this statement was written by someone who knows very little about how private providers staff their aged care homes. Providers rely on a casualised workforce working across multiple locations to make ends meet. This is definitely not an ideal way to ensure staff “know residents well”. And again, many staff have insufficient training to detect clinical changes.
These guidelines were initially released on March 13, a week after the outbreak in BaptistCare’s Dorothy Henderson Lodge in NSW, the first Covid-19 outbreak in aged care. This suggests guidelines written on the run. They were then updated on April 30 (in response to Newmarch House) and then again on July 14 (in response to the unfolding disaster in Victoria).
On Friday, Scott Morrison said: “There has (always) been a plan, and it has been updated, so we completely reject the assertion that there was not a plan, because there was a plan”. However, simply updating guidelines does not make them a “plan”.
The guidelines state that the Health Department does not “accept any legal liability or responsibility for any loss, damages, costs or expenses incurred by the use of, reliance on, or interpretation of, the information contained in the guideline”. This bureaucratic word salad indicates that, if things go wrong, individual aged care providers are responsible, not the federal government.
Aged care homes on their own
The guidelines make it clear that the primary responsibility of managing COVID-19 outbreaks lies with each aged care home. It recommends each home has its own “outbreak management plans in place”. Rather than a single national plan that responds to the global pandemic, the guidelines recommend 2,700 separate plans. Having a plan for each aged care home is utter madness.
Furthermore, aged care homes are on their own. “Each facility is responsible for ensuring the staff are trained and competent in all aspects of outbreak management prior to an outbreak.” (The Department of Health did provide some online training modules for staff.)
It was also the individual aged care home’s responsibility to “ensure that they hold stock levels of all consumable materials required during an outbreak and should have an effective process in place to obtain additional stock from suppliers as needed”.
Again, this is simply extraordinary. Many aged care homes do not supply sufficient incontinence pads for elderly residents, as has been pointed out repeatedly over the years. Expecting all aged care homes to have a sufficient supply of PPE beggars belief.
Focus is health care
Mr Morrison also referred to the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) as part of the so-called “plan” for aged care. Although the words “aged care” are mentioned 21 times, the focus is on the health care sector’s response, not aged care.
For example, there is a reference to encouraging residents to have advance care plans in place. Advance care plans state residents’ wishes when they are dying (e.g. no cardiopulmonary resuscitation) and ensure each individual’s wish is honoured. Encouraging residents to have in place advance care plans is not a strategy to tackle the fundamental issue of saving lives during the grip of a pandemic.
According to Professor Ibrahim, the authors of Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19) were not well informed about the aged care sector. For example, they did not consider the systemic failures and vulnerabilities of the aged care system. In other words, the sector can’t provide consistent quality care under normal conditions, let alone respond to a pandemic.
Ministers indulge in semantics
However much ministers indulge in semantics that states are responsible for health care, the bottom line is that the federal government is responsible for aged care. They pass the legislation, establish the regulations and spend $20 billion every year.
After decades of neglect, in which the federal government has outsourced responsibility for aged care to private providers, it is not surprising that community transmission in Victoria led to outbreaks of COVID-19 in more than 100 private aged care homes.
To prevent older people dying from COVID-19 in aged care homes, the federal government needed a clear National Plan. And it needed this plan in February, when it was obvious the death toll would be higher for older people and those with co-morbidities who became infected.
This plan should have stated clearly: “All residents who test positive should be transferred to hospital.” This strategy has been used in Hong Kong where no residents of aged care homes have died.
Transferring residents to hospital would have ensured they received competent clinical care and would have protected residents who tested negative in the aged care home from acquiring the infection.
Yet no such clear national instructions existed. Instead some aged care homes are encouraged to “cohort” residents into distinct sections of the home to keep separate residents who are positive from those who are negative. Residents are transferred to hospital on a case-by-case basis.
Dehumanising language
When Health Care Minister Greg Hunt described transferring residents to hospital as “decanting”, we saw how much respect he accords vulnerable elderly people in aged care homes. The language of “cohorting” and “decanting” dehumanises older people.
In late July, Minister Hunt said: “Aged care around the country has been immensely prepared.” He did not, however, expand and explain exactly how they were prepared. Were all staff trained in infection control? Did providers have sufficient supply of personal protective equipment? Was there a national plan?
Janet Anderson, the Aged Care Quality and Safety Commissioner, was also confident the sector was prepared after 99.5% of providers had ticked boxes on an online survey to indicate they were prepared.
In his apology to the nation last week, Mr Morrison acknowledged that more could have been done.
“I want to assure you that where there are shortcomings in these areas they will be acknowledged, and the lessons will be learnt, and we will seek to be as upfront, particularly with the families of those who are affected in these circumstances as much as possible.’’
We need deeds, not more words. The government needs to address the systemic failures of the aged care sector that have led to preventable deaths in aged care homes.
First published in Michael West on 16 August 2020