Aged care isn’t working, but we can create neighbourhoods to support healthy ageing in place



Image: Kathleen Brasher, Author provided

Melanie Davern, RMIT University; Geoffrey Woolcock, University of Southern Queensland; Kathleen Brasher, Charles Sturt University, and Rachel Winterton, La Trobe University

This article is part of our series on aged care. You can read the other articles in the series here.


In 2020, the coronavirus pandemic has exposed issues and inequities across society. How we plan for ageing populations and older people is one critical issue that has been neglected for decades. Fresher-faced youth and families have become the demographic focus of increasingly short-term electoral cycles, reinforcing a deep-seated prejudice against ageing and older people.

If Gandhi is right, and the true measure of a society can be found in how we treat the most vulnerable, then Australia has a lot to learn from the 683 deaths from COVID-19 in residential aged care this year. Australia needs a radical shift to policies that better support ageing in place — that is, in their own homes — rather than relying so heavily on underfunded and poorly resourced residential aged care.




Read more:
Despite more than 30 major inquiries, governments still haven’t fixed aged care. Why are they getting away with it?


Residential aged care populations are growing, with 70% of facilities located in major cities and 30% in regional areas. These facilities and current policies are failing our older people as identified by the current Royal Commission into Aged Care. Reform is needed now.

However, residential aged care is only part of the problem of failing to plan adequately for ageing. Neoliberal policies have turned the ageing population into a growing consumer market while filial piety or family caring becomes rarer as economic and social pressures on working families (their adult children) become greater.

Old and young women sit together in a garden
Caring for older family members is becoming rarer in Australia, but remains common practice in Asia.
Chayatorn Laorattanavech/Shutterstock



Read more:
Asian countries do aged care differently. Here’s what we can learn from them


These trends have reinforced health inequities. More than 100,000 people are on the waiting list for in-home support package funding. Over the past two years, 28,000 people have died before receiving any funding.

Older women are particularly vulnerable. In 2007, 75% of women aged over 70 had no superannuation (with superannuation beginning in the 1980s). Two-thirds of residents in aged care were women.

Being age-friendly makes cities more liveable

We need to shift the conversation on ageing to healthy ageing and creating environments that better support ageing in place. Age-friendly places aren’t just good for older people. They also support the needs of children, people with a disability and everyone else in a community.




Read more:
‘Ageing in neighbourhood’: what seniors want instead of retirement villages and how to achieve it


The 50-year-old child-friendly cities movement has increasingly emphasised how the features of a city that make it safe, healthy and accommodating for its most vulnerable citizens can also make it much more liveable for everyone.

In recent research we looked at how the World Health Organisation’s Global Age-Friendly Cities Guide can be applied in local planning. The aim was to develop practical tools to help policymakers and planners assess the age-friendliness of local neighbourhoods. This included the use of spatial indicators to measure the eight domains of the Age-Friendly Cities framework.

Spatial indicators investigating the relationship between health and place are created using geographic information systems (GIS) to map the presence of features within a local area. We have suggested key indicators that can be created and mapped using desktop analysis to understand how age-friendly local spaces are.

Table of key indicators for assessing age-friendly cities

Author provided

One of the most striking features is that many of these suggested measures are important for everyone living locally and not just older people. Examples include good walkability, public open spaces, public transport, affordable housing, local services, cafes, doctors and internet connectivity. Others are age-specific such as in-home aged care.

Most importantly, all of these factors are essential ingredients of healthy and liveable communities. Together, they support better health and well-being outcomes for all. We have mapped many of the suggested measures of age-friendly communities in the Australian Urban Observatory.




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How do we create liveable cities? First, we must work out the key ingredients


The use of additional technology such as sensor and robot technology should also be considered in future community and housing design, but this depends on household internet access. That can be a problem, particularly in regional and remote areas where populations are ageing rapidly and fewer aged-care places are available.

Some of these indicators might not necessarily be feasible for all regional and rural communities. Many regional communities have reduced access to services. However, these indicators still provide an important starting point for discussions with diverse rural older people about what is important and what constitutes reasonable access within their community.




Read more:
The average regional city resident lacks good access to two-thirds of community services, and liveability suffers


If we have learnt anything from this difficult year, then post-COVID recovery must include a broader approach to ageing that extends beyond residential aged care to a focus on healthy ageing. That means better support for people to age in place.

Age-friendly communities enable older people to continue to make significant economic and social contributions to families and communities. However, this can’t occur unless local places plan for all ages and abilities from the beginning.The Conversation

Melanie Davern, Senior Research Fellow, Director Australian Urban Observatory, Deputy Director (Acting) Centre for Urban Research, RMIT University; Geoffrey Woolcock, Senior Research Fellow (Regional Community Development), Strategic Research Projects, University of Southern Queensland; Kathleen Brasher, Assistant Lecturer, Charles Sturt University, and Rachel Winterton, Senior Research Fellow, John Richards Centre for Rural Ageing Research, La Trobe University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Despite more than 30 major inquiries, governments still haven’t fixed aged care. Why are they getting away with it?


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Eileen Webb, University of South Australia; Christie M. Gardiner, University of Newcastle, and Teresa Somes, Macquarie University

This article is part of our series on aged care. You can read the other articles in the series here.


Australia’s aged care sector has been the subject of more than 30 major inquiries and reviews since 1997.

It is fair to say the findings have been highly critical of the way aged care is run in this country. Many of these concerns have been brought to light again — along with new issues raised — in the ongoing Royal Commission into Aged Care Quality and Safety.

Yet, as the royal commission has noted, successive Australian governments have shown a “lack of willingness to commit to change”.

Responses often come years after the review and recount what has been done in an almost tangential way.

Even the establishment of the royal commission was not based on previous inquiries or recommendations, but in response to media exposés of the appalling conditions in some aged care facilities.




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Aged care failures show how little we value older people – and those who care for them


From these dysfunctional circumstances, three questions arise.

First, what are the ongoing issues with aged care in Australia?

Second, why have successive governments been comfortable making do with piecemeal solutions rather than truly “fixing” aged care, once and for all?

Finally, and most perplexingly, why have Australian voters let them get away with it?

What’s the problem?

It is important to emphasise that aged care is predominantly a federal government responsibility. The 1997 Aged Care Act is the main law covering government-funded aged care. This includes rules for funding, regulation, approval of providers, quality of care and the rights of those in care.

Elderly woman looking out a window.
The Royal Commission released a damning interim report into aged care in October 2019.
http://www.shutterstock.com

Since 2019, the federal Aged Care Quality and Safety Commission Act regulates complaints, sanctions and enforcement, but has been criticised for lacking teeth.

The 1997 act diluted many preexisting regulatory protections, such as strict financial accreditation and staffing requirements, and opened the sector up to privatisation. At the time, concerns were raised the new regime could compromise standards of care in aged care facilities and disadvantage older people on lower incomes.

The concerns were raised again and amplified in subsequent years. For example, in 2011, a Productivity Commission report noted Australia’s aged care system needed a “fundamental redesign”.

Here is a brief summary of the recurring issues raised in multiple reports:

  • the huge difficulty people have navigating the aged care system, including finding accurate information about facilities

  • failure to meet the needs of vulnerable older people

  • poor quality care, especially for those with dementia and other disabilities

  • the use of chemical or physical restraints

  • inappropriate staff ratios and poor training

  • the rising cost of care, especially in light of an ageing population

  • adherence to accreditation standards

  • ineffective complaints mechanisms.

Why haven’t these problems been fixed?

One of the major hurdles to real reform is the relationship between the aged care industry and the federal government.

The government funds the sector and provides a relatively “light-touch” oversight, while the providers attend to the day-to-day running of the facilities.




Read more:
Federal government did not prepare aged care sector adequately for COVID: royal commission


However, there is concern this alignment has meant successive governments are not as involved as they should be and proposals for change are diluted by the influence of industry lobbyists.

Another reason for governments’ reluctance to intervene is many of the providers are “too big to fail”. A facility’s licence and government funding can be withdrawn if standards are not met. Yet this rarely happens.

Why? Because if a licence is revoked, residents need somewhere to go. The issues here can be seen in the closure of the Earle Haven nursing home in July 2019. Here, 68 elderly people were left homeless and had to be moved to hospitals and other aged care facilities.

As a further example, Bupa, one of Australia’s largest providers, continues to operate, despite sanctions or failing fundamental assessments.

Why isn’t aged care a vote winner?

After so many inquiries and so many horror headlines, the problems in aged care are well and truly common knowledge. But do Australians care enough about aged care for it to influence their vote — and so, influence the way governments respond?

If we cast our minds back to the 2019 federal election campaign, the hot button issue concerning older people was the potential demise of franking credits and negative gearing.

Australians voting at a polling booth.
Aged care issues did not feature prominently in the 2019 federal election.
http://www.shutterstock.com

In-home and residential aged care barely rated a mention in the campaigns of the major parties.

Even now, despite the publicity surrounding the royal commission, if an election was held today, would this issue actually influence voting intentions? Sadly, it seems unlikely.

During the July 2020 Eden-Monaro byelection, a survey of nearly 700 voters showed while 84% believed the aged care system was “in crisis”, this influenced the vote of less than 4% of respondents. It also ranked last in a list of seven issues of importance.

When heartfelt concern does not translate to winning votes, there is little incentive for the federal government to provide meaningful solutions to well-documented problems.




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The budget must address aged care — here are 3 key priorities


We only need to look to the record spending in the 2020 Budget, which provided only 23,000 extra home care packages and deferred consideration of funding for residential aged care until the royal commission’s final report next year.

It comes back to voters

Why does concern for the plight of people in aged care fail to generate public action?

We suggest it is because many Australians consciously or unconsciously have ageist attitudes — that older people are inherently not important. On this front, look no further than arguments made by prominent commentators about the fate of older people during COVID-19.

Yes, most fair-thinking Australians care about our older citizens, yet until either we or our family members are directly impacted, we do not prioritise it.

If we don’t care enough or care about other things more, nothing will change. And, while this remains the case, the government will have no reason to do more than just tinker with an unsatisfactory status quo.




Read more:
If we have the guts to give older people a fair go, this is how we fix aged care in Australia


The Conversation


Eileen Webb, Professor of Law and Ageing, UniSA: Justice and Society, University of South Australia; Christie M. Gardiner, Associate Lecturer of Law, University of Newcastle, and Teresa Somes, Associate Lecturer, Macquarie University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Aged-care facilities need accredited infection control experts. Who are they, and what will they do?



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Philip Russo, Monash University and Ramon Zenel Shaban, University of Sydney

The Royal Commission into Aged Care Quality and Safety last week released a special report looking at the sector’s response to COVID-19.

Finding the federal government did not adequately prepare residential aged care to deal with a pandemic, the commission made several recommendations designed to safeguard residents moving forward.

One was that the federal government should arrange with states and territories to deploy “accredited infection prevention and control experts” into aged-care facilities to better prepare for, and assist with, management of outbreaks.

But who are these accredited infection prevention and control experts, and what will they actually do?

First, why do aged-care facilites need this?

Infection prevention and control is well established in hospitals and acute care facilities. In Australian hospitals, there’s an average of one full-time infection prevention nurse for every 152 beds. Hospitals typically have an infection control committee, which is ultimately accountable to the hospital board.

By definition, aged-care facilities are not considered to be health-care facilities. Rather, they are social-care settings designed to mimic a home environment as much as possible.

While this is important for residents, this difference can present a range of challenges from an infection control perspective. Unlike hospitals, aged-care facilities typically have various communal areas for socialising, dining and activities, where groups can gather and come into close contact.

Two elderly men talking over a cup of coffee in an aged-care setting.
Aged-care facilities have a range of communal spaces for residents.
Shutterstock

Recent research found while Australian hospitals are guided by different national and state-based standards and guidelines, aged-care facilities generally manage infection control arrangements themselves.

Only 23% of Australian aged-care facilities surveyed had a dedicated infection control committee. More than half reported a lack of staff with specialised qualifications and experience in infection prevention and control.




Read more:
Federal government did not prepare aged care sector adequately for COVID: royal commission


Enter infection prevention and control experts

The royal commission report noted high-level infection control expertise was needed:

  • to assist with the preparation and implementation of outbreak management plans

  • to provide training to staff on the use of personal protective equipment (PPE) and infection prevention and control

  • to provide assistance on day one of an outbreak.

An elderly woman sits in a wheelchair, while a cleaner cleans the floor of her room.
COVID-19 has highlighted the importance of infection control in aged care.
Shutterstock

Besides the accredited infection prevention and control experts, the commission recommended all aged-care facilities should have one or more trained infection control officers as a condition of accreditation.

This could be a registered nurse who has specific training in infection prevention and control. Importantly, they should have access to expert resources and be capable of implementing infection prevention programs.

Employers would be required to support these nurses to take the infection prevention “champion” role, and under the close supervision and guidance of the accredited experts, they could prepare plans for outbreaks like COVID-19.

These plans would include ongoing education around the use of PPE, procedures regarding how to manage residents who become infected, and trigger points for escalating responses.

The COVID-19 crisis in residential aged-care facilities, particularly in Victoria, has shown us how important it will be to have strong and experienced leaders overseeing these plans, and the management of any ongoing and future outbreaks.




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So how are the experts accredited?

The Australasian College for Infection Prevention and Control (ACIPC) is the peak body for infection prevention and control in the Australasian region. It provides “credentialing” for professionals who want to become accredited infection prevention and control experts.

There are three levels of credentialing: primary, advanced and expert. Qualifications and experience determine the level a person attains, but the system is designed so those commencing at the “primary” level can progress to “expert”.

A panel of existing accredited infection prevention and control experts reviews all applications.

They evaluate whether the applicant meets several criteria across five domains: relevant vocation, prerequisites, knowledge, attitude and practice. Criteria include professional qualifications, awards, experience, continuing education, professional activities, and research.

Once credentialed, each member must apply for their accreditation again every three years.

Right now, there aren’t enough

The relationship between certification status of health professionals and the quality of patient care they provide is clear.

In particular, hospitals with infection control programs led by certified or credentialed infection control practitioners have fewer health care-associated infections when compared to those led by non-certified infection control practitioners.




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Older Australians deserve more than the aged care royal commission’s COVID-19 report delivers


According to the ACIPC database, there are currently around 62 accredited infection prevention and control experts in Australia, of whom 42 are at expert level. All are nurses.

The royal commission acknowledged this small number as a limitation. It reflects the fact employers so far haven’t generally required their staff to attain this accreditation — so there’s been little incentive.

But COVID-19 has necessarily changed this. In the short term, facilities must establish a relationship with a local accredited infection prevention and control expert who can support their staff.

Looking forward, employers and providers should be incentivised to support staff to seek higher infection prevention training, and ultimately undergo credentialing.The Conversation

Philip Russo, Associate Professor, Director Cabrini Monash University Department of Nursing Research, Monash University and Ramon Zenel Shaban, Clinical Chair and Professor of Infection Prevention and Disease Control at the University of Sydney, University of Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Older Australians deserve more than the aged care royal commission’s COVID-19 report delivers



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Joseph Ibrahim, Monash University

Amid the ongoing disaster in Victorian aged-care homes, the Royal Commission into Aged Care Quality and Safety yesterday released its special report into the COVID-19 pandemic.

This report finally states who is responsible for aged care — the federal government — finding its actions were “insufficient” to ensure the aged-care sector was prepared for the pandemic.

But the report doesn’t offer us a clear picture of what went wrong and why.

Importantly, its recommendations largely fall short and come too late.

5 main recommendations that don’t go far enough

The report’s first key recommendation addresses the vexed issue of isolating residents from family and friends during lockdowns. The commissioners have asked the government to fund providers to ensure adequate staff are available to facilitate loved ones to visit.

This addresses the universally recognised need for a humane and proportionate response to lockdown, and the need to reduce the mental and physical harms associated with isolation.

But a better approach would be to introduce a mandatory code for visits to aged-care homes during COVID-19, rather than the voluntary code we currently have. We’d also need a way of enforcing this code, including a process to address family concerns immediately.




Read more:
Federal government did not prepare aged care sector adequately for COVID: royal commission


Second, the commission recommends the government create Medicare Benefits Schedule items to increase the provision of allied health services, including mental health services, to aged-care residents.

While this will assist to some degree, a better recommendation would be instituting structured rehabilitation plans for residents with support from care workers. This would ensure the allied health advice provided through these new Medicare items is followed.

This recommendation also fails to address the fact many allied health staff work across multiple services, which increases the risk of infection spread.

The third recommendation requires establishing a national aged-care plan for COVID-19, including setting up a national aged-care advisory body. This is the most obvious step in any emergency response.

The commission indicates the plan should establish protocols between the federal government and states and territories, which may reduce some confusion around who is responsible for what. The plan should also set up procedures regarding who decides whether residents with COVID-19 are transferred to hospital.

As part of the plan, significant outbreaks in facilities are to be investigated by an independent expert, and any lessons promptly disseminated to the sector.

But the commission doesn’t provide any detail on what constitutes an independent expert, a major oversight. Ideally, the experts shouldn’t be directly involved with government departments, the regulator or affiliated groups involved in the pandemic response.




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4 steps to avert a full-blown coronavirus disaster in Victoria’s aged care homes


Perhaps most disappointing is the commission did not highlight that multiple outbreaks in aged-care homes reflect systemic issues rather than individual organisational failures. The most useful information is obtained by investigating every aspect of the sector as a whole. This is a missed opportunity and does not serve the best interests of older Australians.

As for the advisory body, the commission was clear the group Prime Minister Scott Morrison established in August was not sufficient — it lacked the right skill mix and was temporary.

But it’s extremely disappointing the commission has not directed that senior nurses, family members and residents (ideally supported by human rights lawyers) be appointed to the group. The people who will be most affected by the decisions should be directly involved in making them.




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Banning visitors to aged care during coronavirus raises several ethical questions – with no simple answers


The fourth recommendation stipulates all aged-care homes should have one or more trained infection control officers as a condition of accreditation.

The fifth is for governments to deploy accredited infection prevention and control experts into aged-care homes to provide training, and assist with preparing for and managing outbreaks.

These are sound recommendations, but should have been in place more than a decade ago, had we learnt from Hong Kong’s experience with SARS.

The challenges with implementing these recommendations will be having the human resources for such a workforce, including addressing the longstanding issue of health professionals’ willingness to work in regional and remote areas.

Some key omissions

The report’s recommendations are worthwhile, yet all are late in arriving and incomplete. Each recommendation provides a solution to an entirely foreseeable problem.

Notably, there’s an absence of strategies to address the known structural problems in aged care. These are issues the commission itself has previously described, around workforce limitations, widespread neglect of residents, and regulatory failures. They represent barriers to implementing the recommendations.

An elderly woman walks down the corridor of a nursing home using a frame.
Dedicated staff will be deployed to enhance infection control procedures in nursing homes.
Shutterstock

The commissioners also fell into the trap of inappropriate comparisons. References to Australia faring better than selected European and North American countries fail to acknowledge our advantages of being an island continent with lower community transmission and an extra three months to prepare. This provides false reassurance to the public.

We should judge our performance on the disparity between what we could have done and what we did do, rather than against countries in different situations.

There’s more to uncover

It’s not surprising the government has accepted all the recommendations, as each of these initiatives should have already been in place well before the second wave hit Victoria.

The commission has recommended the federal government report on the implementation of these recommendations no later than December 1.




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The budget must address aged care — here are 3 key priorities


Ultimately, this report was not designed, nor did it deliver, an understanding of what went wrong in aged care, and why.

Similarly, the recommendations do not go to the heart of the information gleaned from the appalling and tragic lived experiences of residents, families, aged-care workers and health professionals.

With so many outbreaks, many still ongoing, and tragically, several hundred deaths in aged care already, there remains much we need to uncover.The Conversation

Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Federal government did not prepare aged care sector adequately for COVID: royal commission


Michelle Grattan, University of Canberra

The royal commission into aged care has said government did not prepare the sector well enough for the pandemic.

In a damning report the commission rejected the government’s repeated claim it had a plan for aged care, which is a federal responsibility.

The commission said that now “is not the time for blame” for what happened in aged care, where most of the Australian deaths have occurred – as at September 19, 629 out of 844 total deaths. The latest number of deaths from residential aged care is 665.

But, the commission said, it was clear the measures implemented by the federal government on advice from the Australian Health Protection Principal Committee “were in some respects insufficient to ensure preparedness of the aged care sector”.

It called for immediate action on infection prevention and to ensure residents weren’t cut off from visitors.

In its special report into COVID, the commission said the government should establish a national aged care plan and a permanent aged care advisory body.

Under pressure from evidence to the commission, the government belatedly set up an advisory committee in August but made it clear it was temporary.

As soon as the report was tabled on Thursday, Aged Care minister Richard Colbeck said the government was accepting all its recommendations.

But he continued to insist the government did have a plan for the sector.

“Never before has the aged care sector in Australia faced a challenge like COVID-19,” the report said.

It said the government should fund providers to ensure there were adequate staff available to deal with visits from family and friends.

The understandable restriction of visits “has had tragic, irreparable and lasting effects which must immediately be addressed as much as possible”.

“Maintaining the quality of life of those people living in residential aged care throughout the pandemic is just as important as preparing for and responding to outbreaks,” the report said.

“Funding to support increased visits is needed immediately.”

The commission recommended the Medicare schedule be changed to increase the provision of allied health and mental health services to residents during the pandemic, and the government should “arrange for the deployment of accredited infection prevention and control experts” into facilities.

Announcing $40.6 million as an initial response, Colbeck said the government was already well progressed in delivering some of the recommendations.

The commission said that “confused and inconsistent messaging” from providers, the federal government, state and territory governments had been themes in submissions to it.

“All too often, providers, care recipients and their families, and health workers did not have an answer to the critical question: who is in charge?

“At a time of crisis, such as this pandemic, clear leadership, direction and lines of communication are essential”.

The commission said much had been made during its hearing about whether there was an aged care specific plan for COVID.

“There was not a COVID-19 plan devoted solely to aged care. But there was a national COVID-19 plan that the Australian Government sought to adapt and apply to the aged care sector.”

However “there is a clear need for a defined, consolidated, national aged care COVID-19 plan”.

The commission said the recommended plan should be established through the national cabinet in consultation with the aged care sector.

The plan should establish federal-state protocols, maximise the ability for residents in facilities to have visitors, and establish a mechanism for consultation with the sector about the use of “Hospital in the Home” programs.

It should establish protocols on who would decide about transfers to hospitals of residents with COVID, and ensure significant outbreaks were investigated by an independent expert, with the results disseminated to the sector.

The commission said the government should report to parliament no later than December 1 on the implementation of the recommendations in its report.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Faster public health response might have saved some aged care residents’ lives: Brendan Murphy


Michelle Grattan, University of Canberra

Federal Health Department Secretary Brendan Murphy has admitted some COVID deaths in aged care might have been prevented if there had been a quicker public health response.

Murphy, Chief Medical Officer until mid year, told the COVID Senate committee “if the public health response had been more prompt, then we might have avoided some of the scale of the outbreaks in Victoria”.

He said some of the spread among facilities might have been avoided if the federal-state Victorian Aged Care Response Centre (initiated by the Commonwealth) had been stood up earlier – “if we’d been aware, had prior warning, that the public health response may have been compromised”.

It was not possible to say what proportion of aged care deaths could have been prevented, he said.

“As we have said on many occasions, once you had widespread community outbreaks, wide aged care outbreaks and unfortunately, deaths, particularly of people who are very frail and close to end of life, are inevitable.

“But quite likely that with the benefit of hindsight and responding with a response centre … a little bit earlier, we may well have been able to prevent some of the spread.”

Murphy was treading on sensitive ground for the federal government. Aged care is a federal responsibility. The states have responsibility for public health (although the Commonwealth, under the constitution has a quarantine power).

Murphy, who was still giving evidence, later reacted following the chair of the senate committee, Labor’s Katy Gallagher, tweeting:

He disputed Gallagher’s interpretation, stressing to the committee that the federal government acted as soon as it was aware the public health response was failing, and that it was not in a position to act earlier.

He described the public health response as “a partnership”.

Murphy also said the minutes of the Australian Health Protection Principal Committee were confidential because it is a committee of the national cabinet.

On Wednesday the inquiry into COVID in aged care, done by the aged care royal commission, will be presented to the governor-general. It will be publicly released this weekThe Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.

The government has thrown another $171 million at the problem. But a real plan for aged care has been missing all along


Joseph Ibrahim, Monash University

As deaths in aged care continue to rise, the community may find the Morrison government’s announcement of an additional A$171.5 million to boost its response to COVID-19 in residential aged care reassuring.

The package was agreed by all states and territories at Friday’s National Cabinet meeting, and brings the total Commonwealth funding for aged-care support during the pandemic to more than A$1 billion.

The funding will go towards additional support for the aged-care workforce, the recently established Victorian Aged Care Response Centre, and an Australian Health Protection Principal Committee (AHPPC) Aged Care Advisory Group.

It will also fund grief and trauma support for families, more compliance and quality checks, and support the establishment of emergency response centres in each state and territory.

But this announcement appears to be geared primarily towards dealing with the unfolding disaster wrought by the federal government’s mishandling of the COVID-19 crisis in aged care. It will do little to better prepare the sector for further outbreaks or a third wave.

I would argue we haven’t had clear a plan for residential aged care since the pandemic began.




Read more:
4 steps to avert a full-blown coronavirus disaster in Victoria’s aged care homes


What should a plan look like?

While fighting the current fires is important, here are some of the things we would need to see in a truly forward-looking plan for managing COVID-19 in the aged care sector.

A leader

The first step for the Morrison government is to appoint a leader for aged care, who will be accountable and drive a coherent strategy to address the sector’s challenges.

Recent evidence presented to royal commission and senate inquiry hearings highlight there is no one in charge. It’s clearly not the federal Minister for Aged Care and Senior Australians Richard Colbeck.

The person must be apolitical, without ties to peak bodies or providers, and represent the interests of residents and their families. This position could be similar to a chief health officer, but specifically for residential aged care.

Blurred view of a man sitting in wheelchair through a doorway.
The new funding for aged care will include grief and trauma support for residents and families, among other things.
Shutterstock

Clear goals

Second, we need a clear statement describing the goals and overall objectives this plan will achieve. The latest announcement is a scattergun approach, neither coherent nor strategic. It plugs existing holes.

We have a clear, well-presented strategy for reducing community transmission of COVID-19. We should demand an equally clear strategy for aged care. The focus should be on saving lives, while being humane and compassionate to residents, family and aged-care staff.




Read more:
Should all aged-care residents with COVID-19 be moved to hospital? Probably, but there are drawbacks too


And we must ensure transparency and accountability by making the plan available to and responding to the public in real time. We need to eliminate the diffusion of responsibilities for the aged-care response across the government, health department and the Aged Care Quality and Safety Commission. It creates confusion and opportunities to excuse inaction, and offers no mechanism to redress failures.

We also need a structured approach for rapid two-way information flow between the people in charge and the people on the ground.

A national taskforce

The third step is a national taskforce with the ability to respond to rapidly changing conditions. The AHPPC Aged Care Advisory Group serves to advise government ministers, but only partially addresses this step.

The group’s composition and selection process ought to be publicly visible. The panel needs people with technical expertise, integrity and without any competing interests. There should be at least two members who are consumers — ideally aged-care residents with a human-rights lawyer to support and advocate on their behalf.

Outbreak preparedness

The fourth step is urgently addressing the aged-care sector’s approach to outbreak preparedness and prevention of COVID-19. We must agree to a set of objective measurement tools to assess the approach taken at a facility, organisational and regional level. Then we must be able to evaluate, support and strengthen those plans.

The Aged Care Quality and Safety Commission was allocated an additional A$9.1 million to increase their compliance and quality checks of individual facilities across the country. But additional checks are worthless if we don’t have uniform, transparent checks and balances across the board.




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Let’s heed the warnings from aged care. We must act now to avert a COVID-19 crisis in disability care


Supporting the workforce

The fifth step is genuine support for the aged-care workforce. Staff confidence is key to reducing absenteeism in those who are well and presenteeism in those who are unwell.

While the government has directed A$140 million to staff, including for additional surge workforce, increased training, and retention bonus measures, we’re still missing a strategy to retain staff.

Increasing staff confidence and retaining them in the sector, especially in such a tumultuous time, requires asking, listening and responding to aged-care workers’ concerns. Beyond just offering financial incentives, we need to make them feel prepared, safe and that their concerns are addressed.

One hand reaches out to hold a pair of wrinkled hands on a wooden table.
We need greater transparency and accountability in the aged care sector.
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Respecting residents and families

The final step is recognising the rights of aged-care residents and their families. An advocate not connected to the aged-care providers or government should have access to every aged-care home to be the eyes and ears for residents and their families. This could be achieved with a workforce of just 300 people, each advocate coordinating with ten aged-care homes.

The recent announcement provides for increased availability of grief and trauma support services, with A$12.5 million allocated to supporting residents and their families who have experienced a COVID-19 outbreak. This fails to recognise all residents and families are likely affected by the pandemic and lockdowns, even if they’re not directly affected by an outbreak.

Similarly, the A$1.5 million allocated to ensure regular direct communication from the health department appears to be only for “families and loved ones of aged-care residents impacted by COVID-19”. Is seems an odd approach as our whole country and every aged-care home is affected by the pandemic.

A coordinated, evidence-based national plan

The federal government’s commitment is a small amount, equating to roughly 1.5% of what this already struggling sector receives annually.

While it’s welcome, the majority of funds are allocated to expand existing initiatives which have had limited success.

Throwing money at a problem is not how we develop a coordinated, evidence-based national plan that addresses the known gaps.The Conversation

Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash University

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Poor ventilation may be adding to nursing homes’ COVID-19 risks


Geoff Hanmer and Bruce Milthorpe, University of Technology Sydney

Over 2,000 active cases of COVID-19 and 245 resident deaths as of August 19 have been linked to aged care homes in Victoria, spread across over 120 facilities. The St Basil’s cluster alone now involves 191 cases. In New South Wales, 37 residents were infected at Newmarch House, leading to 17 deaths.

Why are so many aged care residents and staff becoming infected with COVID-19? New research suggests poor ventilation may be one of the factors. RMIT researchers are finding levels of carbon dioxide in some nursing homes that are more than three times the recommended level, which points to poor ventilation.

An examination of the design of Newmarch in Sydney and St Basil’s in Melbourne shows residents’ rooms are arranged on both sides of a wide central corridor.

The corridors need to be wide enough for beds to be wheeled in and out of rooms, but this means they enclose a large volume of air. Windows in the residents’ rooms only indirectly ventilate this large interior space. In addition, the wide corridors encourage socialising.

If the windows to residents’ rooms are shut or nearly shut in winter, these buildings are likely to have very low levels of ventilation, which may contribute to the spread of COVID-19. If anyone in the building is infected, the risk of cross-infection may be significant even if personal protective equipment protocols are followed and surfaces are cleaned regularly.

Why does ventilation matter?

Scientists now suspect the virus that causes COVID-19 can be transmitted as an aerosol as well as by droplets. Airborne transmission means poor ventilation is likely to contribute to infections.

A recent article in the journal Nature outlines the state of research:

Converging lines of evidence indicate that SARS-CoV-2, the coronavirus responsible for the COVID-19 pandemic, can pass from person to person in tiny droplets called aerosols that waft through the air and accumulate over time. After months of debate about whether people can transmit the virus through exhaled air, there is growing concern among scientists about this transmission route.




Read more:
Is the airborne route a major source of coronavirus transmission?


Under the National Construction Code (NCC), a building can be either “naturally ventilated” or “mechanically ventilated”.

Natural ventilation requires only that ventilation openings, usually the openable portion of windows, must achieve a set percentage of the floor area. It does not require windows to be open, or even mandate the minimum openable area, or any other measures that would ensure effective ventilation. Air quality tests are not required before or after occupation for a naturally ventilated building.

Nearly all aged care homes are designed to be naturally ventilated with openable windows to each room. In winter most windows are shut to keep residents warm and reduce drafts. This reduces heating costs, so operators have a possible incentive to keep ventilation rates down.

From inspection, many areas of typical nursing homes, including corridors and large common spaces, are not directly ventilated or are very poorly ventilated. The odour sometimes associated with nursing homes, which is a concern for residents and their visitors, is probably linked to poor ventilation.

Carbon dioxide levels sound a warning

Carbon dioxide levels in a building are a close proxy for the effectiveness of ventilation because people breathe out CO₂. The National Construction Code mandates CO₂ levels of less than 850 parts per million (ppm) in the air inside a building averaged over eight hours. A well-ventilated room will be 800ppm or less – 600ppm is regarded as a best practice target. Outside air is just over 400ppm

An RMIT team led by Professor Priya Rajagopalan is researching air quality in Victorian aged care homes. He has provided preliminary data showing peaks of up to 2,000ppm in common areas of some aged care homes.

This figure indicates very poor ventilation. It’s more than twice the maximum permitted by the building code and more than three times the level of best practice.

Research from Europe also indicates ventilation in aged care homes is poor.

Good ventilation has been associated with reduced transmission of pathogens. In 2019, researchers in Taiwan linked a tuberculosis outbreak at a Taipei University with internal CO₂ levels of 3,000ppm. Improving ventilation to reduce CO₂ to 600ppm stopped the outbreak.




Read more:
How to use ventilation and air filtration to prevent the spread of coronavirus indoors


What can homes do to improve ventilation?

Nursing home operators can take simple steps to achieve adequate ventilation. An air quality detector that can reliably measure CO₂ levels costs about A$200.

If levels in an area are significantly above 600ppm over five to ten minutes, there would be a strong case to improve ventilation. At levels over 1,000ppm the need to improve ventilation would be urgent.

Most nursing homes are heated by reverse-cycle split-system air conditioners or warm air heating systems. The vast majority of these units do not introduce fresh air into the spaces they serve.

The first step should be to open windows as much as possible – even though this may make maintaining a comfortable temperature more difficult.




Read more:
Open windows to help stop the spread of coronavirus, advises architectural engineer


Creating a flow of warmed and filtered fresh air from central corridor spaces into rooms and out through windows would be ideal, but would probably require investment in mechanical ventilation.

Temporary solutions could include:

  1. industrial heating fans and flexible ventilation duct from an open window discharging into the central corridor spaces

  2. radiant heaters in rooms, instead of recirculating heat pump air conditioners, and windows opened far enough to lower CO₂ levels consistently below 850ppm in rooms and corridors.

The same type of advice applies to any naturally ventilated buildings, including schools, restaurants, pubs, clubs and small shops. The operators of these venues should ensure ventilation is good and be aware that many air-conditioning and heating units do not introduce fresh air.

People walking into venues might want to turn around and walk out if their nose tells them ventilation is inadequate. We have a highly developed sense of smell for many reasons, and avoiding badly ventilated spaces is one of them.The Conversation

Geoff Hanmer, Adjunct Professor of Architecture and Bruce Milthorpe, Emeritus Professor, Faculty of Science, University of Technology Sydney

This article is republished from The Conversation under a Creative Commons license. Read the original article.

Grattan on Friday: Morrison government needs to improve, rather than defend, its poor COVID aged care performance


Michelle Grattan, University of Canberra

The state of aged care preparation in the era of COVID-19 is, it seems, in the eye of the beholder.

Vastly different claims emerged this week, when the royal commission examining the sector turned its attention to the handling of the pandemic.

According to the senior counsel assisting the commission, Peter Rozen, QC, federal authorities had no COVID-19 plan specifically for aged care, always potentially a major risk area. And, Rozen noted, compared with many countries, residents of facilities form a very high proportion of Australia’s deaths.

The government disputes the lack-of-plan allegation and has a different take on the statistics.

Brendan Murphy, secretary of the health department and until recently Australia’s chief medical officer, appearing before the commission, insisted there had been proper planning, and said the death proportion reflected not a failure in aged care but the low number of fatalities in the general community.

If you were taking a bet on who most people would believe, Rozen would be short odds.

Morrison knows the government is highly vulnerable on the issue. Aged care is a federal responsibility. It affects millions of Australians, counting those with relatives in homes. People’s anger buttons are easily triggered when things go wrong.

Some around the government might like to discount Rozen’s attack as being what counsels-assisting do at royal commissions. But his claims were backed by witnesses, from highly regarded geriatrician Joseph Ibrahim of Monash University to union officials with members on the front line.

They also resonated after the numerous first-hand accounts in the media from families as the virus has ripped through well over 100 facilities in Victoria. Currently, there are more than 1,000 cases among residents and over 1,000 among staff, linked to these homes.

Politicians have been congratulated during the pandemic for listening to experts, but according to Ibrahim, there was not enough aged care expertise applied in the preparations to firewall the sector.

It’s hard if not impossible, anyway, to build adequate safeguards when the structure itself is so compromised, due to bad decisions and neglect over many years.




Read more:
Royal Commission into Aged Care reminds Health Department Secretary Brendan Murphy it sets the rules


A sector operating with low paid, often short term, casuals who pick up work across facilities and often have inadequate English (complicating even basic training) was always inviting disaster.

Health Minister Greg Hunt declared recently, after Victoria Premier Dan Andrews said he wouldn’t want his mother to be in some of these places:

The idea that our carers, that our nurses are not providing that care, I think, is a dangerous statement to make. They are wonderful human beings and I won’t hear a word against them.

This misses the point. No one doubts the commitment the majority of the carers have to their work. But the nature of the workforce brings dangers for residents.

Many facilities run on narrow financial margins. The rules allow them to keep their staffing to a minimum, in terms of numbers and skill.

Nor has regulatory oversight been adequate. Often it is families and the media that have exposed neglect and abuses. Morrison announced the royal commission in September 2018 a day before an ABC Four Corners investigation was to air.

The for-profit system emphasises the idea of facilities being “home-like”, which sounds great but can mean inadequate specialised care and challenges for inflection control.

The word “tragic” is thrown around too much by politicians and media. But what’s happened in aged care during COVID-19 has indeed been a tragedy.

It’s just possible if the pandemic had come two years later, after next year’s final report of the royal commission had forced some reform, that fewer lives would have been lost. But even with the system as it is, the evidence indicates better planning could have saved lives.

That’s certainly Ibrahim’s view. In his precis of evidence, he argued “hundreds of residents will die prematurely because people failed to act”.

We had enough knowledge to do better. We failed because when residents are treated as second class citizens there is an absence of accountability and consequences for those responsible for aged care in Australia.

There was “failure to provide the same health response to residential aged care that was delivered to the rest of Australia.”

The government has been playing catch-up on aged care all through the pandemic. It had to put substantial money in to help with staffing; it was slow to acknowledge the importance of masks; it set up a co-ordinated response in Victoria belatedly; National Cabinet only a week ago stepped up preparations in other parts of the country.

Morrison is now confronted at two levels: there must be root and branch reform after the royal commission, and his government is under immediate pressure over this week’s indictment.

The government’s tactic of inserting Murphy into the commission’s witness list was a miscalculation.

It seemed to assume the commission would defer to Murphy when he sought to make a statement to reject Rozen’s claims. But he was refused permission to commence with the statement (which he delivered at the end of the session) and all his appearance did was highlight the government’s sensitivity.

When he summed up the hearings on Thursday, Rozen did not resile from his initial criticisms. He concluded the problems in aged care had been foreseeable; “not all that could be done was done”; and the challenge remained.

Picking up a recommendation from Ibrahim, Rozen urged an “age-care specific national coordinating body to advise government”. It would bring together expertise in aged care, infection control and emergency preparedness.

With such a body, “a national aged care plan for COVID could still be put in place,” Rozen said.




Read more:
Government rejects Royal Commission’s claim of no aged care plan, as commission set to grill regulator


Although the advisory body is not a formal recommendation, commissioner Tony Pagone endorsed it among “practical things that perhaps should not wait.”

The virus doesn’t wait and nor should the measures that need to be implemented to deal with the virus wait either.

The government, which has previously signalled more assistance for aged care in the budget, should stop insisting it has done everything well and act immediately on this and some of the other suggestions made in the COVID-19 hearings.

Morrison said this week in a Facebook message, “I want to assure that where there are shortcomings in these areas they’ll be acknowledged. And the lessons will be learned.”

The government likes to talk about wanting a reform agenda, but this should not be just an economic one. Aged care must be near the top of any serious “reform” to-do list, and vested interests should not be allowed to limit necessary changes.

In his end-of-year ministerial reshuffle, prompted by Mathias Cormann deciding to quit parliament, Morrison should elevate the aged care portfolio from the outer ministry to cabinet.

Having the post in cabinet would send a positive signal but, more importantly, it would encourage a wider range of ministerial eyes on an issue that’s been mishandled for as long as anyone can remember.

Veterans’ affairs is in cabinet, and most families would think aged care is just as worthy of a place.The Conversation

Michelle Grattan, Professorial Fellow, University of Canberra

This article is republished from The Conversation under a Creative Commons license. Read the original article.