Virus lays bare the $200b health system

 afr.com  08/14/2020 04:19:58 

COVID-19 has ripped through these facilities, exposing both the frailty of the residents and the chronically underfunded aged care system, its poorly designed private provider model and patent lack of readiness for the pandemic.

To his credit, it was Prime Minister Scott Morrison who established the royal commission. He recently nailed the central issue when he suggested nursing homes are in reality pre-palliative wards, accurately describing a system that is screaming for a National Disability Insurance Scheme-style rethink.

This lack of readiness was bluntly called out by the counsel assisting, Victorian health and safety expert Peter Rozen, QC, who went directly to what he thought was the problem.

"A degree of self-congratulation and even hubris was displayed by the Commonwealth government, he said. Perhaps they were reflecting the general mood in the country: that we were through it."

Morrison rejected that claim on Friday, but admitted failures as another three private homes were taken over by Victorian hospitals on Thursday.

The state coroner is gathering evidence for hearings that will catalogue what promises to be a horror story of multi-agency and private operator failings.

No accountability

The same complacency was also on trial in Melbourne as a public accounts committee began the painful process of examining the Victorian government's missteps in containing the virus.

Months of filibustering and avoidance about what went wrong in the fateful hotel quarantine program  known as Operation Soteria  continued, despite the best efforts of several opposition MP's to finger who exactly was responsible.

The absurdity stopped being amusing by the third day when Danny O'Brien, Nationals MP and former chief of staff to Barnaby Joyce, yet again asked Transport Minister Jacinta Allan who was the minister ultimately responsible for the hotel quarantine program.

NSW is years ahead of Victoria in the use of administrative data to drive high-performance delivery and program design.

"Well, Mr O'Brien, you and your colleagues have canvassed this on multiple occasions during the course of this week and know that I have nothing to add to the comments that have been made already over the course of this week on that matter," Allan responded.

If only.

Minister after minister, secretary after secretary, put on a masterclass in obfuscation, leaving few answers to what lessons should be learnt from the hotel breach.

Estimates committees are more show-pony events than serious reviews and this one was no better.

Precious time to focus on the obvious shortcomings in the aged care catastrophe, so called "bottlenecks" in early contact tracing and the runaway infections in the health system, was wasted amid the febrile chase to nail which minister should take the fall for whatever were the hotel quarantine mistakes.

All that will now need to wait until November for Justice Jennifer Coate's report on what went wrong.

At the heart of the issue is how does government organise itself for an emergency such as a pandemic.

The Victorian public service has completely redesigned itself around eight missions to fight the pandemic.

It is the sort of silo-busting, flat-structure approach that every contemporary review of the public service has pushed for.

But it has meant accountability has been lost in a blur of cross-government committees, co-ordination mechanisms and multi-agency operational plans that no one seems to own.

Opaque accountability and confused governance have emerged as a central theme in both the breakdown between the federal and state government health departments over the management of aged homes, and the mishmash of federal and state agencies that has responsibility for quarantine.

'Human health is not the responsibility of the ABF'

One of the most revealing statements came from the Australia Border Force in response to a media report that one of its officials had mistakenly cleared the arrival in Sydney of the Ruby Princess.

That was the boat that NSW Health ticked for disembarking, leading to more than 600 infections and 21 fatalities across the country.

Four days before it docked  amid rising concerns about COVID-19-riddled cruise ships  Morrison declared there would be bespoke arrangements for arriving cruise ships "under the command of the Australian Border Force" to ensure that the relevant protections are put in place.

ABF did not seem to get the memo, as last week it responded to a media inquiry by stating: "Human health is not the responsibility of the ABF."

Which of course begs the question as to who is responsible, with plant and animal oversight the domain of the Australian Quarantine and Inspection Service.

The answer is the federal Health Department, which under the authority of the powerful Biosecurity Act has oversight of this function.

The Ruby Princess report is due to be released Friday afternoon and hopefully will make recommendations on how to remove these ambiguities.

Meanwhile, how the system was meant to work when the state governments took over the management of the quarantine hotels remains one of the unanswered questions.

Yet again there is the theme of confused responsibility  hopefully to be answered by another review, by former federal health secretary Jane Halton.

From the grandstand the failure of the large Victorian contact tracing and isolation team to hold the breach so as to avoid level three, and now level four, restrictions has been particularly problematic and deserves transparent review so lessons can be learnt.

Victorian Chief Health Officer Brett Sutton admitted "bottlenecks" and the transmission rates effectively overwhelmed the team.Justin McManus

Chief Health Officer Brett Sutton has admitted there were "bottlenecks" and told estimates this week the nature of the virus and the extent of transmission that was occurring effectively overwhelmed the team, meaning that much of the large-scale testing in late June was effectively being wasted.

The net result was that community transmission, or so-called mystery cases, ballooned in early July  and the rest is history.

That team felt the red hot poker of federal government frustration and with the help of some rigour from the Australian Defence Force this week reported internationally stellar performance numbers as part of national dashboard set up by Canberra to bring more rigour to contact tracing.

There are a lot of moving pieces and people in the contact tracing and isolation program, and there continue to be too many local stories of people claiming delays.

Behind the lack of a muscular response to surging community transmission are claims of under investment in public health in Victoria. Public health is a very broad program and doing a like-for-like comparison is problematic, but clearly post COVID-19 there will be an obvious demand for health security investment.

It will be among the many claims on the public purse across the entire ambit of government.

Also being questioned is the core architecture of the Victorian health system, which has long claimed pre-eminence among its state government peers.

It may be a case of living off past glories.

Victorian AMA president Julian Rait this week pointed the public accounts committee to what he sees is the problem.

"In Victoria there is no central oversight or planning which co-ordinates and integrates the different arms of public health, primary care and public hospitals, important and inter-connecting parts of our health system," he told MPs.

"Additionally, there is no strong interface with the beleaguered aged-care sector  a situation of course that is exacerbated further by the arbitrary division of responsibilities that has occurred between state and federal governments."

The publication of the contact tracing dashboard came as another former federal health secretary, Professor Stephen Duckett, admonished all governments  and Victoria's in particular  for the lack of meaningful data to sensibly manage the pandemic.

Duckett told The Australian Financial Review there were lots of anecdotes but little proper reporting.

"[T]here is no data published that shows the overall pattern and how each jurisdiction is performing," he said. "This makes it difficult for the community and policymakers to understand how the pandemic is being managed."

The issue is not so much a lack of data. The health system is awash with data and performance dashboards, but it is highly operational, disconnected and not built for transparency or serious citizen engagement.

NSW is years ahead of Victoria in the use of administrative data to drive high-performance delivery and program design. The NSW government has had near real-time postcode-level data and mapping since early in the pandemic.

In Melbourne we await an email each afternoon of unstructured epidemiological data from Sutton. There is still is no consolidated public data repository, making the whole exercise more like a primary school report card.

Over $200 billion a year is spent on healthcare. We deserve better.

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