Three-quarters of deaths from COVID-19 in Australia have been in aged care homes. Experts say that the pandemic is only exposing systemic weaknesses. Sophie Cousins reports. For the first few months of the COVID-19 pandemic, Australia stood out as an exemplar of how best to respond. At the time of writing, Australia has recorded just over 27 000 cases in a country of 25 million people, with fewer cases per person than most other high-income countries. While Australia has a natural advantage as an island, it also swiftly built surge capacity in the health system; deployed robust test, trace, and isolate systems; rolled out effective public health campaigns; and provided the eligible population with an economic safety net. The country also declared a pandemic before WHO. But as time went on, a major weakness emerged: residential aged care homes. There have been just over 2000 cases of COVID-19 in residential aged care in Australia. Of the 904 deaths from COVID-19 in the country at the time of writing, 682 have been in aged care homes, mostly in the state of Victoria. That 75% of the country's deaths have occurred in such facilities gives Australia one of the highest rates worldwide of deaths in residential aged care as a percentage of total deaths. It has left families grieving and experts angry that their pleas to reform the sector had long been ignored. “Homer Simpson could have seen the catastrophe in aged care coming with COVID-19 because it was there in your face”, said Professor Joseph Ibrahim, head of the Health Law and Ageing Research Unit at Monash University (Melbourne, VIC, Australia) and an expert witness at Australia's Royal Commission into Aged Care Quality and Safety. “All I know is that you can't accept things as they are, because they're not right.” In 1997, the Australian Government transformed the system under the Aged Care Act into a free-market model that was, in Ibrahim's words, “ill-conceived and never worked”. Transforming the model of care meant that aged care and health care would be treated as two different separate industries. As a result, private investment into aged care was able to flourish, which, experts say, turned people from patients into consumers. “Back then, aged care was criticised as too institutional, so it was packaged as a social model of care whereby you don't need regulation”, said Kathy Eagar, professor of health services research and director of the Australian Health Services Research Institute at the University of Wollongong (Wollongong, NSW, Australia). “On that basis, they deregulated staff. By packaging residential aged care as social care, it dumbed down the care and created the perfect storm. This has been a disaster waiting to happen.” Eagar says that, by turning aged care into social care, the sector has been able to justify not having good infection prevention and control measures, sufficient staff ratios, and adequately trained staff. “The system is not fit for purpose. When you have a system that doesn't even require a nurse to be on the premises then the whole thing is going to be a disaster… The pendulum has swung too far”, she said. In 2011, the full funding and policy responsibility for aged care in Australia moved from the state and territory level to the federal government. Today, the sector represents a multibillion-dollar industry that is predominantly publicly funded but largely outsourced to the private sector. Experts say that the pandemic has brought to light systemic problems arising from such a policy. “I don't think anything has gone wrong per se—it was already wrong”, Ibrahim said. “There were not enough workers to start with; the workforce that exists doesn't have the training for a contemporary aged care system. They're not equipped to manage disease complexity and they're not equipped to deal with ethical human rights issues. So, then COVID-19 arrives and there are not enough staff, staff who don't know what they're doing, staff who haven't been trained in infection control.” The first major COVID-19 outbreaks in Australia began in April in aged care facilities in Sydney, initially at Dorothy Henderson Lodge and then Newmarch House. By the time the outbreak at Newmarch House was over in June, 19 residents had died, 37 additional residents had been infected, and 34 staff had fallen ill. These outbreaks should have sounded a major alarm for the sector to prepare for the worst—in addition to harrowing stories coming out of Europe—but soon, COVID-19 swept through Victoria's private aged care homes as stories and images emerged of the horrific conditions inside. A 95-year-old woman in a Melbourne care home was left with ants crawling over a wound on her leg. Other residents had not had food or water for 18 h. There were faeces on the floor. Hundreds of residents were locked in their rooms for weeks as relatives were shut out from visiting their loved ones. Not only were residents infected, but hundreds of low-paid, low-skill workers in the homes were infected too. “If you depend on a low-paid casual workforce who go from home to home, then you can expect COVID-19 to just spread, which is exactly what has happened in Victoria”, Eagar said. “COVID-19 is now a major occupational safety and health risk.” State-run aged care—which operates under the Safe Patient Care Act 2015, which enshrines in law minimum numbers of nurses and midwives to care for patients—has recorded very few COVID-19 cases and no deaths. Private facilities have no such quotas. “Private providers don't necessarily care about aged care—they care about making a profit”, said Sarah Russell, public health researcher and aged care advocate. “What is aged care for? Is it because older people are a great cohort to make money off? Why are we locking people down and locking relatives out? What type of life is that for them?” However, not all private providers make profit, some organisations including Anglicare Sydney, which runs Newmarch House, and BaptistCare, which runs Dorothy Henderson Lodge, are not-for-profit. In 2018, after evidence of abuse and neglect was exposed in residential aged care, Australia's Prime Minister, Scott Morrison, announced a Royal Commission into Aged Care Quality and Safety. As the Royal Commission continued into 2020, it turned its focus towards the worsening situation with COVID-19 in the aged care system. “This is the worst disaster that is still unfolding before my eyes in my entire career…There was a level of apathy, a lack of urgency and an attitude of futility which lead to absence of action”, Ibrahim told the Royal Commission in early August. In a special report published in early October, the Royal Commission found that the government's attempt to prepare the aged care sector for COVID-19 was “insufficient”. The Commission made six recommendations, which include calling on the federal government to establish a detailed national aged care plan for COVID-19 (it has repeatedly denied that it did not have a plan) and to deploy infection control experts into nursing homes as a condition of accreditation. The report also describes infection prevention and control measures in facilities as “deplorable”. “We heard of workers being told they could only use one glove rather than two, and a guideline at a residential aged care facility that only permitted two masks per shift”, the two commissioners, Tony Pagone and Lynelle Briggs, wrote. Recognising that maintaining the quality of life was just as important as preparing for a pandemic, the Commission urged the government to help aged care providers to “ensure there are adequate staff available to allow continued visits to people living in residential aged care by their families and friends.” A spokesman for Anglicare Sydney said Anglicare agreed with all the recommendations. “The Royal Commission says basically everything that we wanted to be said...we support the recommendations,” the spokesman said. “We want to continue to care for the elderly and vulnerable in society.” Russell, who is calling for the Aged Care Act 1997 to be rewritten from a human rights perspective, said there must be transparency over staffing in facilities so families can make an informed decision on where to send their loved ones. “Staffing transparency is the key”, she said. Eagar, who has undertaken research commissioned by the Royal Commission into the adequacy of residential aged care staffing, found that quality and safety in homes is driven by four factors: total staff numbers, staff skill mix, staff continuity, and clinical governance. © 2020 Ryan Pierse/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. “Our aged care sector basically failed on every one of those dimensions and that is unlike Australia—we're well above the international standards on health care”, she said. “It's unusual for us to fail so badly but we are much worse than comparable countries.” Eagar has also proposed restructuring the aged care system to include age-friendly community services, plus home-based primary-level and secondary-level aged care services and out-of-home tertiary-level aged care services. Meanwhile, Ibrahim hopes that COVID-19 will give rise to smaller, community-run residential aged care homes that have a sense of community and social responsibility. Whether the system, which looks after 200 000 people a year, will be reformed remains to be seen. “COVID-19 has really thrown a spotlight onto the residential aged care sector and shown it to be a broken system in desperate need of reform”, Eagar said. The Royal Commission is scheduled to release its final report in February next year. For more on the aged care Royal Commission see https://agedcare.royalcommission.gov.au/sites/default/files/2020-10/aged-care-and-covid-19-a-special-report.pdf
