There are lessons from the COVID-19 pandemic for improving residential aged care. Around the world, the pandemic has disproportionately affected older people especially those living in residential aged care. Residents have the highest case fatality rate and generally accounted for 50% of all deaths from COVID-19 and yet comprise less than one percent of the general population . Already two damning reviews from Australia  and the United Kingdom  describe how governments poorly managed the pandemic in aged care.
The lessons to be learned are examined according to the actors in a sociotechnical system. This allows a critique at each layer of the system from government policy to the tasks at the bedside.
Level 1 Government
The pandemic revealed deep fractures between the State and Federal governments’ responsibilities and roles. These created confusion and incoordination of the emergency response causing unnecessary deaths. The Federal Government provides $14 billion per year in funding to cover the costs of personal and health care for residents. The State government is responsible for public health outbreak management and access to acute hospital care.
The governments and their agencies did not prioritise aged care, despite the sectors known vulnerabilities to COVID-19 and failed to proactively institute a specific aged care response as part of a national plan to manage the pandemic . Improving aged care in Australia requires greater engagement of both levels of governments to provide clarity of roles and responsibility in provision of medical and health care.
Level 2 Regulator
The Aged Care Quality and Safety Commission played a significant role in the national emergency response to the pandemic for aged care. It is a very unusual role for a regulator and was not replicated in any other country around the world. The Commission’s role varied from being an advisor partnering with providers to, an autocratic watchdog imposing sanctions in the midst of a large outbreak.
The regulator lacked the technical knowledge and public health expertise and as a consequence provided ill-advised reassurances that the aged care sector was well prepared. The regulator also failed to enforce initiatives that protected residents’ rights, for example visitation—relying instead on a voluntary industry code of conduct . Improving aged care in Australia requires a better resourced regulator with the technical skills to address the major clinical issues. It also must be willing to be rigorous and uncompromising in actions to protect residents first and foremost.
Level 3 Peak bodies and stakeholder associations
Aged care sector has over fifty peak bodies and stakeholders and yet the views of residents and their loved ones were almost invisible during the pandemic. This allowed significant breaches in respecting residents’ human rights.
Breaches in rights were evident in the nature and extent of lockdown, visitation, limiting access to health care or transfer to acute hospitals and use of restrictive practices. These went ahead unchallenged. Improving aged care in Australia requires hearing the residents’ voices through a new national entity that is supported by human rights lawyers and advocates.
Level 4 Approved providers
Evidence of profiteering by some providers while others were in a tenuous financial position were presented in equal measure as the economic consequences of the pandemic became visible.
The obvious lack of accountability is highlighted by over $1.5 billion in additional government funding for the pandemic response. Improving aged care in Australia requires greater transparency and accountability around funding. There must be detailed public disclosures so that residents and taxpayer are informed of how providers spend government funds.
Level 5 Management
The Communicable Diseases Network Australia (CDNA) guidance material for pandemic response  placed an unfair and unrealistic burden on nurse managers to deliver the public health interventions. Matters such as sourcing personal protective equipment and, development of protocols with the acute hospitals are better managed at a regional jurisdictional level not by individual managers. The CDNA guidance document included a disclaimer which could only create further doubt about the substance of the content and relay to managers that they are ‘on their own’.
The nurse managers were also largely ignored and not included in government and health departments emergency response groups advising about the pandemic response. Improving aged care in Australia requires more cohesive action at regional and jurisdictional levels to coordinate care and share knowledge. It also must include nurse managers who have the contextual experience and knowledge to identify and advise on the most effective and efficient reforms.
Level 6 Staff
The aged care workforce was inadequate in number, under-skilled and undervalued prior to the pandemic. The casualisation of the workforce is one approach to reducing costs and the low pay rates create an environment for staff to work in multiple places—a factor in the outbreaks. The level of absenteeism during an outbreak reflects the fear and uncertainty of staff who have not been trained or provided with assurances that their health and by extension their families health was important. Improving aged care in Australiarequires a better trained, better paid, nationally registered workforce.
Level 7 Work
The nature of work in aged care is very poorly understood. This gap was evident in the professional health experts advising the pandemic emergency response. Residents require hands on care, physical distancing in confined spaces is very difficult, the facility environment is non-clinical and ill-equipped for optimal infection-control.
The pressures of the daily workload in usual circumstances became much greater with the use of personal protective equipment. This along with new temporary support staff who lack knowledge of residents needs—compounded the crisis creating gaps in care for residents who were not infected. Improving aged care in Australia requires detail understanding the actual care needs of residents along with the time, effort and expertise required to deliver it.
The COVID-19 pandemic place a spotlight on the long-established failures within the aged care system. This should galvanise the community to start holding the government, regulator and providers accountable for their actions and inactions .
About the author
Professor Joseph E Ibrahim MBBS, GradCHE, PhD FAFPHM, FRACP, is a Professor at the Department of Forensic Medicine, Monash University, Victorian Institute of Forensic Medicine where he is head of the Health Law and Ageing Research Unit, an Adjunct Professor at Australian Centre for Evidence Based Aged Care, La Trobe University, and is a practising senior consultant specialist in geriatric medicine at Ballarat Health Service with over 30 years of clinical experience. Joseph’s ongoing research is investigating approaches to reducing harm to older persons and improving quality of life. Joseph provided evidence and been cited in the Australian Law Reform Commission into Elder Abuse, Carnell and Paterson Report, the Commonwealth Senate Inquiry for protecting residents from abuse and poor practices, House of Representatives Inquiry and the Royal Commission into Aged Care Quality and Safety. Joseph was one of three people recognized by the Sydney Morning Herald Good Weekend’s “People Who Mattered 2019: Health”. Joseph has published over 300 papers including 160 articles in peer review journals. He is also a producer, co-writer and narrator of four short films about ethical issues in persons with dementia and ageing.
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 Royal Commission into Aged Care Quality and Safety. Aged care and COVID-19: a special report. Canberra: Commonwealth of Australia. Available from: https://agedcare.royalcommission.gov.au/sites/default/files/2020-10/aged-care-and-covid-19-a-special-report.pdf (2020)
 Amnesty International. As if expendable: The UK Government’s failure to protect older people in care homes during the COVID-19 pandemic. London: Amnesty International. Available from: https://www.amnesty.org/download/Documents/EUR4531522020ENGLISH.PDF (2020)
 Industry Code for Visiting Residential Aged Care Homes during COVID-19. Available at: https://www.cota.org.au/policy/aged-care-reform/agedcarevisitors/
 CDNA national guidelines for the prevention, control and public health management of COVID-19 outbreaks in residential care facilities in Australia. Available at: https://www.health.gov.au/resources/publications/cdna-national-guidelines-for-the-prevention-control-and-public-health-management-of-covid-19-outbreaks-in-residential-care-facilities-in-australia
 Royal Commission into Aged Care Quality and Safety. Counsel Assisting’s Final Submissions. Canberra: Commonwealth of Australia. Available at: https://agedcare.royalcommission.gov.au/media/29099