IN A submission to the Parliament of Victoria’s Inquiry into the Victorian Government’s Response to the COVID-19 pandemic, Associate Professor Julian Rait, President of the Australian Medical Association (AMA) (Victoria), recommended that “a Royal Commission be called into Victoria’s response to the COVID-19 pandemic”.
The submission describes 11 “missteps” by the Victorian Government, including the mismanagement of the hotel quarantine system (which is now subject to a judicial inquiry).
The submission was dated 31 July 2020, at the peak of Victoria’s second wave, with 629 new cases of coronavirus reported in the 24 hours to 30 July, and a 7-day average to 31 July of 436 new cases per day. At 9 September, the 7-day average was 70 new cases in Victoria per day.
Several of the “missteps” can be refuted.
In his submission to the Inquiry, Associate Professor Rait said that the Victorian Government created a public perception of “tolerance of large demonstrations”, such as the Black Lives Matter rally. The Victorian Government, police, and the Chief Health Officer urged people to stay at home and to avoid attending rallies. There was a clear message to the Victorian community that the restrictions were essential (here and here). There is no evidence that this message fostered public complacency about the restrictions on gatherings.
Aged care facilities
Associate Professor Rait’s submission takes the Victorian Government to task for the St Basil’s Aged Care Home tragedy, saying: “Siloed decision-making within the Victorian Government … put individuals at risk such as the decision to furlough all St Basil’s staff without ensuring a plan for care for residents, leaving their basic needs unmet”.
Accountability for the St Basil’s debacle cannot be attributed exclusively to the Victorian Government.
Premier Daniel Andrews defended the decision to quarantine the staff, in order to contain the COVID-19 outbreak. There were reports of subsequent deficiencies in residents’ care. However, the actions of the Victorian Department of Health and Human Services (DHHS) will have saved lives by reducing the potential transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) from staff to residents.
St Basil’s is a private facility. It is under the jurisdiction of the Australian Government. As such, the Australian Government shares some accountability for the St Basil’s debacle. The Australian Government’s aged care regulator took 4 days to notify the federal Department of Health about the COVID-19 outbreak. The replacement surge workforce was implemented by the Australian Government Department of Health.
The Royal Commission into Aged Care has criticised the Australian Government for failing to develop a COVID-19 plan for the aged care sector.
Questions have been raised about St Basil’s preparedness for a COVID-19 outbreak, and about its strategies for preventing COVID-19 in staff and residents. These issues are the responsibility of St Basil’s management. They are not the responsibility of the Victorian Government.
Further, on 24 August, the Victorian Aged Care Response Centre (VACRC), a joint initiative of the state and federal governments, launched a web-based incident management system (the Victorian Health Services Coordination Hub) to track and monitor COVID-19 cases, outbreaks, and personal protective equipment supplies in the aged care sector. This was an appropriate, but late response to the COVID-19 aged care crisis in Victoria. Would there have been fewer deaths, and less distress for residents, if the VACRC had been implemented at the earliest opportunity in the crisis?
There have been no outbreaks of COVID-19 in aged care facilities run by the Victorian Government.
Communication with the community
I agree with Associate Professor Rait that communication with culturally and linguistically diverse groups has been suboptimal. There were mixed messages on isolation after testing, and on exercise for people with a confirmed diagnosis of COVID-19.
Some asymptomatic people who were associated with workplace outbreaks or community outbreaks, but not defined as close contacts, were told at testing services that they did not need to isolate after testing pending their SARS-CoV-2 test result.
Some asymptomatic contacts, and some symptomatic people were also told by the testing service that they did not need to isolate pending their results.
Some people who had COVID-19, and some people who were contacts, were permitted to exercise outdoors, therefore breaching isolation and quarantine respectively.
The mixed messages seemed to reflect a perfect storm of misunderstanding and misinformation, promulgated by a combination of inconsistent facts and advice from news media, social media, health care services, and the DHHS.
These problems, undoubtedly, should not have occurred. These problems have been corrected, as indicated in the information currently provided in the coronavirus section of the DHHS website.
Although not mentioned in Associate Professor Rait’s submission to the Inquiry, it is clear that the contact tracing system used by the DHHS will require a review. The number of new cases of COVID-19 in Victoria per day rapidly increased from 73 on 1 July to 685 on 4 August. The total number of cases, and the rate of increase in daily new cases exceeded the capacity of the DHHS system to provide effective contact tracing.
A contact tracing system will inevitably be capacity-limited. An effective contact tracing system will need to maximise the number of cases (total and rate of increase) that can be managed.
There are no easy answers here. A review published in The Lancet earlier this month concluded that “large-scale manual contact tracing is therefore still key in most contexts”. The value of automated contact-tracing tools, such as the COVIDSafe app, has yet to be proven. This review estimates that for contact-tracing apps, population uptake of 56–95% is required to control COVID-19. Another review published in The Lancet examined the impact of testing delays and tracing delays on the R0 (reproduction number). Not surprisingly, this review concluded that onward transmission of infection from an index case is reduced with fewer delays in both testing and tracing.
Although not examined or discussed in these reviews, perhaps a significant flaw in any contact tracing system is the human factor; for example:
- not getting tested;
- delaying getting tested;
- not responding to contact attempts by DHHS (ignoring phone calls and text messages);
- not isolating after testing;
- not isolating after a positive SARS-CoV-2 test;
- not recalling close contacts;
- declining to identify close contacts.
- not responding to tracing (ignoring phone calls and text messages);
- not quarantining.
Perhaps a decentralised community-based model will work more effectively; for example, the door-knocking system for following up index cases and contacts implemented in the UK (and in Victoria now).
An effective contact tracing system requires the cooperation of the community in which it is being implemented. Education by DHHS about the public’s roles and responsibilities in contact tracing will support the public’s “buy in” to an effective system.
Social distancing and wearing masks should be considered as preventive approaches for testing and contact tracing; fewer cases, fewer contacts.
Singapore has developed a decentralised community-based model that includes an app (Trace Together), and a highly evolved system of protocols and integrated multidisciplinary roles involving activity mapping, analytics, surveillance, and door-to-door inquiries. This video explains Singapore’s contact tracing system.
The contact tracing models in Taiwan and Iceland have been praised for their cooperative strategies in response to the pandemic.
Evaluation is awaited for the systems in the UK, Singapore, Taiwan and Iceland.
Communication between government and GPs
In his submission, Associate Professor Rait said that:
“General practitioners need a much stronger two-way dialogue with the state government so that model development, enactment, collaboration and feedback can be improved … Indeed, there has been a lack of a two-way dialogue and strong relationship between the state government and general practitioners – and a lack of support from the state government over many years … AMA Victoria believes there needs to be a genuine, long-term culture shift in DHHS’s to improve its engagement with stakeholders. In a pandemic, we see that disconnect and stress play out very clearly, whereby GPs are ignored or excluded from our disaster preparedness.”
I disagree. The relationship and communication between government and general practice has been fit for purpose, but, of course, this could be improved.
General practice has been well supported through the pandemic by the Australian Government, the Victorian Government, the Australian College of Rural and Remote Medicine, the Royal Australian College of General Practitioners, and the Primary Health Networks. Australian Government initiatives include telehealth, GP-led respiratory clinics, and the provision of personal protective equipment for general practices. Information and updates have been provided by newsletters, notifications and webinars. The information is available, not always in a “spoon-fed” format, but GPs are expected to know how to find the information that they require.
Although the Australian Government and the Victorian Government have generally provided appropriate and timely information, two-way communication, undeniably has been deficient. GPs do not have clear communication systems to contact the government for questions, advice and comments. Dedicated phone lines (hotlines), dedicated email addresses, and designated departmental GP liaison officers could help to overcome some of these problems.
I refute the contention that general practice has not been involved in planning and implementing the response to the pandemic. The role of primary care in the pandemic is well described in this article published in the MJA.
General practice has been integral to the pandemic response, providing care for people with COVID-19 (85% of whom are managed in the community), and for people with other acute problems, chronic disease, and preventive activity needs. General practice has an ongoing role in managing people with COVID-19-related mental illness, COVID-19-related social problems, and long (or post-acute) COVID-19.
Notification of COVID-19 to DHHS
GPs (and all doctors) have always been required to notify urgent infectious diseases to the Victorian DHHS, by phone, 24/7. Online notification for COVID-19 has now been introduced, and this provides an additional option. This is an example of a response by DHHS which has improved the relationship and communication between DHHS and GPs.
The role of the Chief Health Officer in Victoria
It has been revealed at the Parliamentary Inquiry into hotel quarantine that Professor Sutton, Chief Health Officer, was excluded from the role of State Controller by the DHHS Secretary, contrary to the state’s pandemic plan, and contrary to Professor Sutton’s wishes. The State Controller has overall responsibility for emergency response operations.
There have been suggestions that the Victorian Government has not adequately sought public health advice and expertise in its response to the pandemic.
Professor Sutton has said that he first learned about problems in hotel quarantine when he read reports of them in newspapers.
In his submission to the Inquiry, Associate Professor Rait described “missteps” by the Victorian Government.
I partly agree with him.
There is evidence that some mistakes have been made in regard to COVID-19 outbreaks in aged care facilities; communication; contact tracing; and governance. Consequently, there have been some adverse events and adverse outcomes. In many instances, culpability is shared with the Australian Government or with other agencies. The “missteps” must be considered in the context of the pandemic, with many issues and challenges that could not have been anticipated in pandemic planning.
The Victorian Government has taken steps to correct any missteps that are its responsibility.
The Victorian Government did not promote tolerance of large gatherings.
In my opinion, the Victorian Government’s response to the pandemic has perhaps been “good, but could do even better”.
Internal analysis will be enough to identify issues and determine timely solutions, for the ongoing response to this pandemic, and for planning the response to the next pandemic.
An inquiry with the powers and the expense of a Royal Commission is not required.
Dr Andrew Baird is a GP at the Elwood Family Clinic in Victoria. He is a tutor in professional practice for medical students at the University of Melbourne.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.