Is there an alternative future for aged care?

The coronavirus has been described as a cunning and invisible enemy by virologists and politicians. They should know what it takes!

As its genetic code compels it to continually reproduce to survive, the virus effectively seeks out whatever opportunity it can to continue to reproduce. In the process, it uncovers our points of weakness, exposing the pre-existing vulnerabilities in its hosts’ lives.

With the now well-known impact on older people, it seems inevitable that aged care homes would be a focus for the disease. And so it has come to pass, our past failings in aged care, as in many other areas, have been exposed.

In Australia, 199 of the 278 deaths caused by COVID-19 as of 8 August, 71.6 per cent of the total and almost three in every four, have been of residents in aged care homes. This is not just about consumer preferences. These are matters of life and death for hundreds and, internationally, hundreds of thousands of older people.

Data compiled by the Canadian Institute of Health Information in late May 2020 shows that Australia is not unique. Deaths in aged care homes made up 42 per cent of all COVID-19 deaths reported across the OECD.

In Australia, 28 per cent of all deaths from the coronavirus at that time were from residential aged care. Germany reported that 34 per cent of all COVID deaths were in such care homes, the Netherlands 15 per cent (a figure that has since increased significantly). The US reported 31 per cent, the UK 27 per cent, Italy 32 per cent, France 48 per cent and Spain 66 per cent. Highest of all was Canada, where deaths in aged care homes represented 81 per cent of the comparatively large national total of deaths due to COVID-19.

These figures probably under-report the extent of such deaths. There was a failure to include care home deaths where COVID was not explicitly diagnosed in many countries, including the UK and the USA. This was often due to a lack of testing. Other data problems mean that the full extent of such miserable and untimely deaths may remain hidden for many months, possibly years.

The reported death rate in aged care homes, however, is clearly remarkable, especially when we know that such homes have only a small proportion of all older people. In Australia, this residence rate is approximately one in 20 older people, around a sixth of the death rate.

Alongside the grief of those who have lost loved ones, there is much anger at the failure of authorities to prevent the high incidence of such foreseeable fatalities. Alongside this, there were also deeply painful prohibitions in many homes that prevented lifetime partners and other family carers from even seeing their loved ones in the weeks before they died.

In Australia, much of this anger has been directed at government. The rationale is not hard to find: the marketised, privately operated system of aged care facilities, funded and licensed by the Commonwealth; the high proportion of the workforce that has been casualised or outsourced under commonwealth employment legislation, so that vital staff often need to work even when sick and are employed in a number of different facilities. The lack of registered nursing staff employed and the failure to stipulate even minimum levels of such professional staffing add to the litany of accusations.

Similarly, problems of poor-quality care have been documented over many years, most recently by the Royal Commission. Yet there has been no effective action. Worse still, there was a failure in Victoria in July to learn from the earlier NSW experience in April and May. Each home was left to its own devices for weeks while the pandemic took hold.

Prime Minister Scott Morrison tried to deflect the blame to the Victorian government when on Wednesday 30 July he pointed out that: "In every country where there is sustained community transmission this will find its way into aged care facilities … and that is what we’re seeing … in Victoria." If that was so well known, why were effective preventative measures not taken? Why was there no Commonwealth response for nearly a month?

Under the legislation, the Commonwealth, it can be argued, has a duty of care that it failed to exercise. Yet while each of the specific failings of the Australian system require an urgent response, at least we have a national system – something the Canadian researchers noted earlier had found to be generally associated with a relatively low death rate in residential care.

Might there be also be factors beyond politics at play here? One feature noted by epidemiologists is the closed nature of care homes. Without use of special quarantine measures, the congregate care model which involves co-locating large numbers of high need service users of advanced age together, seems to be conducive of outbreaks of infection. Just like the Ruby Princess and other infectious cruise ships, the institutional model of care, as we used to call it, provides a ready breeding ground for such hidden viruses. This is a situation easily exacerbated by regulations and rules that limit access to hospital care and risk cross contagion between residents and staff.

But is there an alternative? Clearly major reform of aged care policy in Australia as in many other comparable countries is required urgently. It is also important to implement the pandemic approach recommended by the WHO and other health authorities. Ensure expert infection control teams are available to supplement and supervise care home staff. Isolate any person who is infected (resident or staff member) by removing them at the first opportunity to hospital or otherwise physically isolating them from non-infected residents.

Beyond that, the pandemic evidence suggests that community care may offer huge protective benefits. Figures available from the Department of Health show that as of 8 August, seven people receiving Australian Government–subsidised care in their own home had died. This is 2.5 per cent of all COVID deaths, massively under the 71.6 per cent in residential care, despite the fact that the numbers of people receiving such care at home massively outnumber those receiving residential care.

Could it be that care provided at home offers a more effective and relatively safe, less contagion prone form of support? Might care delivered to people isolated at home be a comparatively affordable and effective general counter-measure to the spread of the pandemic?

Yes, there are problems – not least the lack of data on the current operation of community care services which would help document either their success or failure. To this we must add the huge waiting lists in Australia for Home Care Packages, the low level of intensity of services currently available in this country, and the general reliance on staff with a limited level of professional training, the low rates of pay and very often insecure conditions of employment including no paid pandemic leave for causal staff (although it has now been granted to residential care staff).

Add to this many other problems besetting the staffing and equipment of our community care provisions. It is clear that at present the system is far from ideal and that there is only a limited capacity to substitute care at home for residential care.

Community care also typically relies to a significant degree on unpaid family carers and this imposes major stresses on them, as research undertaken in Germany during the pandemic has documented. There is clearly much that can and needs to be done to lift the level and standard of provision.

But the broad outlines of an affordable alternative approach are clear.  Improve community care, invest in making it more widely available and capable of providing levels of support that will really enable its users to remain at home.

As the royal commission turns its attention to the coronavirus and aged care, we can be confident. There is an alternative. We don’t have all the answers yet, but we can learn, fast.

Let’s not pretend the cunning virus is the only one capable of adapting.

Michael Fine is Honorary Professor, Sociology at Macquarie University.

Note:  Figures cited in this article are from:

Australian Department of Health https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers

Canadian Institute for Health Information https://www.cihi.ca/en/long-term-care-and-covid-19-international-comparisons

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