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In October, the government made a new plan for hospitals – but it was never updated and one of the key drugs it was based on still hasn’t arrived. By Rick Morton.

Hospital plan: ‘Try very hard to avoid getting Covid until March’

A nurse moves a patient from the emergency department Covid-19 red zone at Sydney’s St Vincent’s Hospital.
A nurse moves a patient from the emergency department Covid-19 red zone at Sydney’s St Vincent’s Hospital.
Credit: Lisa Maree Williams / Getty Images

In mid-October, as the Delta wave exacted its peak toll on hospital systems in the two most populated states, 31 chief executives from the country’s Primary Health Networks were treated to an offhand comment from the federal Department of Health.

The executives – who led the PHNs funded by the Commonwealth to co-ordinate care between GPs, allied health and state hospital systems – were on a Microsoft Teams meeting with senior bureaucrats on unrelated matters when the Health team mentioned a plan was being developed to “transition Covid care to the community”.

The plan – although it was not yet clear to those on the call – was to keep as many Covid-19 positive patients out of hospital as possible. It would be based in part on a drug that still has not arrived in the country and at the time wasn’t approved for use. Crucially, the plan was not updated when Omicron hit and numbers surged out of control.

The Teams call happened on October 12. The official communiqué, from first assistant secretary Simon Cotterell, was not sent until October 25. It represented a massive shift, in line with national cabinet deliberations, to relieve pressure on the nation’s hospital systems by shifting the focus of Covid-19 care to GPs.

Cotterell’s email said the government would retool an online system called Healthdirect to link Covid-positive patients to primary care without them going to a hospital.

“Any management of Covid-positive cases by Healthdirect would be of very low-risk patients only,” his email said. “Discussions are well advanced with NSW and Victoria about this arrangement, and the system will be designed so that other jurisdictions can readily join.”

This was the new normal, run out of a Living With Covid Taskforce within the Department of Health. It involved the “intensive” involvement of general practitioners across the country. But as one observer told The Saturday Paper, the “greatest weapon” in their fight on the front line was withheld: Paxlovid.

On October 17, Health Minister Greg Hunt announced the federal government’s ability to “secure” 500,000 courses of Pfizer’s investigational oral antiviral tablet Paxlovid. Early clinical trials showed the drug could dramatically slash hospitalisation rates among infected people with high-risk conditions.

After this deal, clinical trial data from Pfizer revealed there was an 89 per cent reduction “in risk of Covid-19-related hospitalisation or death from any cause compared to placebo in patients treated within three days of symptom onset”.

Many things changed between early October and November 2021, but two things are significant: Omicron arrived, Paxlovid didn’t.

“Now when the government says we’re not looking at case numbers, we are just looking at hospitalisations and intensive care and people dying, well, that’s the drug,” a high-ranking source familiar with the discussions between health networks and the federal department tells The Saturday Paper.

“The frustrating thing is the terminology ‘we’ve secured it’. Well, we all know what that means.”

Paxlovid, which has been administered in the United States and Israel for more than a month, was given provisional approval by the Therapeutic Goods Administration on January 20 alongside a less effective oral pill from Merck. Neither drug has reached Australia.

Since December 1, there have been more than 1200 deaths as a result of Covid-19 here, with most of those happening this month. According to a source who spoke on the condition of anonymity, the first prescription Paxlovid won’t be available in Australia until early March.

“Absolutely, people have died who otherwise wouldn’t have,” they said.

As summer began, GPs and Primary Health Networks were left in the dark about the new “care in the community” plan. They begged for an advertising campaign to inform the public about the change in Covid-19 management – call your GP first and if things worsen, they’ll send patients to hospital – but none happened.

These groups also repeatedly asked for progress on Paxlovid supplies and heard nothing. There was no training and until late December the Commonwealth threatened to revoke telehealth Medicare rebates entirely.

All the while, cases spiralled.

“It was a classic case of snatching defeat from the jaws of victory,” the primary health source said of the reopening strategy.

“We are aghast at how primary care has been abandoned. They have been left to their own devices. There has been no support.”

 

Hospitals sit at the top of the health system pyramid in Australia, but each level of care below the acute sector has the ability to shape what happens in this pandemic.

Deep into the second year, as the Delta variant swept through New South Wales and Victoria, an underpaid and overburdened healthcare workforce was stretched beyond capacity. Filling positions to vaccinate the country, cover for sick or isolating employees and oversee ballooning “Hospital in the Home” and community care programs – which includes GPs – placed extraordinary strain on a finely linked system.

According to its own guidelines, the NSW Hospital in the Home system is reserved for clinically stable patients and “is a hospital substitution program which means that the patient admitted to HITH would otherwise be accommodated in a hospital”. In Victoria, its HITH program “is an alternative to an inpatient stay”.

As the Victorian Department of Health policy states: “Patients are still regarded as hospital inpatients, and remain under the care of their hospital doctor. Care may be provided by nurses, doctors, or allied health professionals, and additional home supports arranged as required.”

NSW policy required that every person admitted to HITH was given a pulse oximeter, a critical device that measures oxygen saturation levels. This did not happen.

More than 40 people have died at home due to the SARS-CoV-2 virus, mostly in NSW and Victoria. Almost half of these cases were known to health authorities.

In the October 25 communiqué from the Department of Health, Simon Cotterell told Primary Health Network chiefs that the government “is procuring up to 200,000 pulse oximeters for the National Medical Stockpile for use by general practices and [general practice respiratory clinics] in managing Covid-positive patients.”

The request for this tender, however, was not published until November 2. Many countries around the world have been using these inexpensive devices to manage Covid-positive patients since the middle of 2020.

In the NSW government’s most recent weekly update, for figures to January 23, there were more than 4500 hospital and healthcare workers furloughed and in isolation because of community exposure or potential workplace exposure in the state. This figure is down from a high of 5800 the week before but still almost quadruple the numbers out of action just before Christmas.

On Thursday, the number of hospitalisations due to Covid-19 in NSW dipped by about 70 patients to 2722. Although this number has been relatively stable over the past week, the number of people in intensive care has fallen to 181 from a January 19 high of 217.

In Victoria, hospitalisations and ICU admissions appear to have peaked on January 17, with 1229 patients admitted and 129 patients in intensive care. On Thursday, those figures had fallen to 1057 and 117.

Proportionally, South Australia’s Covid-19 intensive-care and high-dependency admissions were almost on a par with NSW, representing 23 per cent of all occupancy on January 18, according to data compiled in the national common operating picture release. In Queensland, such admissions represented 15 per cent of all ICU and high-dependency occupancy.

Beyond the hospital, community admissions such as those for Hospital in the Home are still elevated. NSW had almost 10,000 patients “under the care of NSW Health” on January 16 but not in hospital, down from about 14,000 in September last year. At the same time, some 166,000 cases were described by NSW Health as being “self-managed”.

Although Victoria does not regularly report outside-hospital care for Covid-19 patients, there were more than 1600 in its HITH program in September last year when there were just 143 ward patients.

These programs are important pressure-release valves, but they require resources to run properly.

In his memo to health networks, Simon Cotterell acknowledged this fact.

“The plans will connect Covid-19 patients with the right level of care – whether that is self-monitoring, care from a general practice or general practice respiratory clinic, or for higher risk patients, care in a hospital or a Hospital in the Home arrangement,” he said.

“The pathways will need to include testing arrangements, clear and rapid escalation arrangements for people to receive hospital-based care if needed, and effective arrangements for after-hours access to assessment and care.”

Later, Cotterell added that the government is “looking at … funding for PHNs to commission practice nurses, nurse practitioners and approved medical deputising services to provide home visits to Covid-positive patients in the community when the supervising GP is unable”.

“This will not be for routine monitoring but provided on an exceptions basis to avoid escalation to hospital (unless escalation to hospital is clearly indicated),” he said.

The senior bureaucrat whose email has been obtained by The Saturday Paper added that the government is “also looking at … preparing for the broader availability of rapid antigen testing”.

Despite claims from Scott Morrison this was not the Commonwealth’s job, his government did eventually lodge tenders for the supply of these crucial at-home tests, two-and-a-half months after Cotterell sent his email.

 

These measures were all promised before Omicron was discovered. When the variant arrived, plans were not adapted. As Omicron surged through most of Australia over the summer, it triggered a ripple effect through all health systems.

More people in the community with symptoms meant pressure on ambulance systems remained at crisis levels. The NSW Ambulance Service, for example, can cope with up to 3500 calls a day. On January 1, combining new year celebrations with an explosion in Covid-19 cases, there were 5120 jobs.

“People were waiting 10 to 12 hours for an ambulance and at one point the response time for a low-acuity job was 22 hours,” a paramedic told The Saturday Paper.

“Calls have come back down again recently but the biggest problem now is the sheer burnout we are seeing. And we just do not know what will happen next. Maybe we clear Omicron and some new horrific variant pops up.”

In both aged and disability care, where staff are paid considerably less than their counterparts in the hospital system, the competition for surge resources has been fierce and in some cases hopeless.

An aged-care nurse told The Saturday Paper the problem is chronic. “With staff furloughed, we are working understaffed  most days,” she says. “Where there should be six care staff working in the morning, there are four. Where there should be five care staff in the evening, there are two.

“It is impossible to access agency staff and all the homes in the organisation I work for are experiencing similar issues.”

This is occurring in a system that was not appropriately staffed or funded before Covid-19. This nurse’s mother, also in an aged-care home in another state, died following a Covid-19 diagnosis.

“The home in which she lived was in lockdown. Almost half of the staff were furloughed as they also contracted the virus,” she said.

“When I entered her room she was unconscious in her chair. The home had engaged agency staff to cover the furloughed staff and they appeared to have no knowledge of the home, the layout, or the residents, which ultimately increases the risk to the residents.”

On January 19, the Victorian government declared an emergency “code brown” across all public hospitals in metropolitan and major regional centres. The code will last at least until mid-February and possibly until early March. It allows hospital authorities to redeploy staff easily and cancel leave. Elective surgery and all non-urgent procedures have been temporarily paused in Victoria from January 6, marking the third period in three years when such interventions have been delayed.

Victorian Health Minister Martin Foley said on Tuesday that although numbers have stabilised they have done so at “extraordinarily high levels”.

Foley said a new advertising campaign will be launched in the state, encouraging people to recover from Covid-19 at home if they are low risk. “The notion that we are out of this,” he said, “is well and truly premature.”

 

In June last year, a Melbourne family was plunged into crisis when their young adult son suffered a traumatic brain injury after a skateboarding accident. The man had two rounds of emergency surgery to relieve bleeding on and around his brain. He spent 11 days in intensive care.

“On the day he was moved to the Acquired Brain Injury Unit in Caulfield we went into lockdown five. Then lockdown six came in about 10 days after that finished,” his mother told The Saturday Paper.

“We were not able to see him from the time he went into the unit until a couple of days before he was released, five weeks later. Cognitively he was doing really well, but physically he was having bad headaches and nausea and therefore [was] not able to eat.”

After being released into care at home, and with a third of his skull still sitting in a fridge at hospital, the man and his parents endured a long, often silent, waiting game to find out when his cranioplasty surgery could be done. It was an elective surgery category two – not urgent but needing to be done within 90 days – and all the while the man continued to suffer serious headaches and sickness.

“On November 3 he had a phone meeting with the registrar from the neurology department saying that he was now on a waiting list … some time in the next 90 days as his condition was not life-threatening,” his mother said.

“We opened up on December 15 and I could see by the numbers that this date was slipping further away.”

The man’s mother called on January 4 and was told she would get a call back in a few weeks. She called again on January 19. “By now the code brown had come in so things were looking pretty bad.”

The man was ultimately advised to go straight to emergency at Mulgrave Private Hospital in Melbourne’s south-east, tell them of his severe headaches and nausea, and see if a surgeon could operate. That surgery happened last Sunday, January 23.

“From the time he left hospital he had a lot of cerebral fluid floating around in his head. We only found out in early January that this would have been the cause of the headaches and migraines,” the man’s mother said.

“Mulgrave Private did a CT scan which showed the fluid putting pressure on the brain, and we were told by the physician that ‘this is not normal’ and that ‘this surgery should have been done six to eight weeks after you left hospital’.”

The family was lucky to secure a spot and be able to pay the $5000 out-of-pocket costs after private health insurance. The Saturday Paper has been inundated with stories like this – and others from people less fortunate.

At Wollongong Hospital, Mark (not his real name) had a kidney removed due to cancer and caught Covid-19 during recovery on the ward. What he saw, after many previous visits to the same hospital, was a workforce under extreme pressure.

“One nurse said she had worked 18 hours straight and had come back for another shift after a six-hour break,” he said. “I don’t blame the nurses at all but at one point I was given the wrong medication.”

Mark was sent home while positive with Covid-19. He was not given a pulse oximeter.

In another case, at St Vincent’s hospice in Sydney, an elderly woman contracted Covid-19 and was sent to the dedicated ward at St Vincent’s Hospital.

“We couldn’t get information on her for 24 hours,” her daughter-in-law said. “It was a comedy of errors. This is not about the staff – they have been swamped – but we spent all day on the phone trying to get through to anyone who could tell us what was happening.”

The elderly woman died on the ward on Tuesday.

“There is no other word for what is happening in our health system at the moment than clusterfuck. And it was happening prior to Covid,” her daughter-in-law said. “You can have as many photo opportunities as you want in front of a brand-new, brilliant hospital, but if you do not provide the staffing, the infrastructure is nothing.”

 

In identifying a way to relieve pressure at the acute end of the health system, the federal government has overlooked the realities of life in primary care.

“At one point, I kid you not, the Department of Health thought that general practitioners would be having face-to-face meetings with Covid-positive patients,” the senior primary health source said.

“They then went on to say, ‘Oh, well, we will provide GPs with personal protective equipment’ and that has not happened.”

Again, an almost “unbelievable” lack of preparation, according to this source, is behind a health system that has buckled and left hundreds of thousands of Australians with inadequate or interrupted care.

Alcohol and drug services have been hobbled, palliative care reduced to an inhumane level, aged and disability care is suffering, chronic disease management has been paused or reduced, mental health services for people with moderate to high needs is almost impossible to access, and necessary surgeries have been delayed.

There is also the matter of Covid-19 itself. Until Paxlovid arrives, there are few good management options.

“Our advice, and I am serious about this, is that if you are in a high-risk category and can manage to avoid getting Covid-19, then you should try very hard to avoid getting it until March,” the health source said. “That’s the cold reality of it.”

This article was first published in the print edition of The Saturday Paper on January 29, 2022 as "Hospital plan: ‘Try very hard to avoid getting Covid until March’".

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Rick Morton is The Saturday Paper’s senior reporter.

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