cohealth welcomes the opportunity to contribute to the Public Affairs and Estimates’ Committee Inquiry into the Victorian Government’s Response to the COVID-19 Pandemic.
The COVID-19 pandemic has confronted Victoria with unprecedented challenges, to health, employment, financial security and social connectedness and wellbeing. These challenges are being felt most acutely by people who were already experiencing disadvantage. COVID-19 has highlighted and exacerbated existing inequalities. Governments at all levels have a clear obligation to ensure that no-one is left behind in responses to the pandemic. We have a critical opportunity to build a fairer and equal society through the recovery policies and actions that are implemented.
cohealth recognises the extraordinary efforts of the Victorian Government, community groups and organisations, business sector and individuals to respond to the threats of COVID-19. We applaud the many supports introduced by governments to mitigate the worst impacts of the pandemic.
At the same time cohealth has observed where there is opportunity for improvement in the system response , from inadequate engagement with community groups to effectively communicate information about the virus, through to the lack of integration of care between COVID-19 testing and health care responses.
This submission will focus on the impacts on the communities cohealth works with. From the learnings from these experiences we hope that enhanced responses can be developed to improve the health and wellbeing of the community and for planning for future crises.
cohealth’s work in hotspot areas of the north and west of Melbourne
Given the concentration of the covid-19 outbreak in the north and west of Melbourne, cohealth has been central to the COVID-19 pandemic response. As a non–government organisation, cohealth has been able to be extremely agile and rapidly setup a range of services, where they are needed, including the following:
- provided a rapid primary health care response to residents of the North Melbourne and Kensington high rise towers hard lockdown. With one day’s notice, cohealth was able to establish and staff on site primary care clinics to provide residents with health and social support services staffed by general practitioners, nurses and allied health staff on site;
- COVID-19 testing – cohealth has established 11 fixed and mobile COVID-19 testing clinics at locations across inner, northern and western suburbs as required;
- cohealth has continued to proactively contact at risk clients (the elderly, people with complex health conditions, limited English) to provide them with up to date information and offers of support;
- continuing to provide health and social support services to people experiencing homelessness including the thousands who have been provided with accommodation in hotels;
- providing ongoing primary care, community engagement and health concierge programs on site to residents of 28 high rise towers in Flemington, North Melbourne, Kensington, Ascot Vale, Footscray, Collingwood, Fitzroy and Carlton.
- established an innovative program to ensure all people who test positive to COVID-19 are assessed for clinical risk and for social supports to ensure they are able to isolate at home. The COVID Referral and Pathways Service, led by cohealth and in partnership with Melbourne Health, North West PHN and DHHS ensures people who test positive for COVID-19 are assessed and quickly streamed into clinical pathways (GP or hospital) and provided with social supports such as housing and financial aid to enable isolation at home.
The central role of community health services in COVID-19
Community health services across the state have played a key role in the health service response. With close connections to, and trusted relationships in, their local communities, as well as existing understanding of the needs of these communities, community health services have been able to make critical contributions to the state-wide COVID-19 response.
The community health sector has a history of rapid mobilisation in response to other disasters, such as the recent bushfires. Community members who face barriers to accessing mainstream services find accessible and welcoming health care and social support services at their local community health centres. However, despite this critical role that the community health sector plays it has not been valued to the same degree as other parts of the health system. As a result, the sector has not seen any real funding increases for many years, despite the increasing community need for services stemming from increasing inequality and hardship.
The effective response of community health services to the COVID-19 has demonstrated the vital role community health services play in providing early intervention and care, effectively reducing the load on hospitals and overall health system cost. The Victorian community health sector is in a unique position to deliver targeted, integrated and person-centred services for vulnerable and disadvantaged Victorians. In doing so, the sector has the potential to address systemic challenges and contribute to the delivery of sustainable healthcare in Victoria. To do this, the community health sector needs to be recognised as a key partner in health system design, planning and operation, with appropriate investment to grow the sector and support this critical work.
Melbourne’s lessons – from hard lockdown to a holistic model of care that prevents outbreaks
On 4 July 2020, nine public housing high rise towers in North Melbourne and Flemington became subject to a Public Health Directive that placed residents into detention in order to prevent the spread of COVID-19. The lockdown came into effect very quickly, without any notice for residents.
Significant attention has been paid to how the hard lockdown of the high-rise housing towers in North Melbourne and Flemington was undertaken. The Victorian Ombudsman is conducting an investigation into the treatment of people and conditions of detention at 33 Alfred Street, North Melbourne.
Key issues were:
- the visible police presence which was distressing for the residents in the towers. cohealth received feedback that seeing cohealth doctors and nurses was comforting to residents (one third of residents were existing clients of cohealth). cohealth’s nursing and medical staff made an effort to walk the grounds so that residents could see cohealth uniforms. cohealth recommends that if any future hard lockdowns are required that a health led response rather than a police led response is a more appropriate response to a public health emergency;
- residents reported difficulties in accessing culturally appropriate food, health care, medication and other practical supports they needed with the information and contact mechanisms overwhelmed with demand and waiting times;
- despite the diverse communities represented in the towers written information and public announcements was initially provided in English which caused confusion and a lack of understanding of what was occurring.
cohealth was notified hours before the lockdown and was able to immediately mobilise staff to setup a clinic for residents. cohealth has a trusted relationship with residents and communities built over many years of providing services in the local area. Our involvement during the hard lockdown included:
- establishing primary care clinics at each of the two lockdown sites to ensure that residents had access to medicines and other non-COVID related health care while in isolation. These services were provided via telehealth and in person where necessary with staff donning PPE to visit residents in their flat. Services provided include primary and allied health services, counselling, case work and medication. The on-the-ground and phone response was resourced by cohealth staff including bi-cultural workers who are multilingual.
- Mobilising a community health response to nearly 3,000 residents in lockdown to provide COVID-19 tests. We used a range of staff (whoever was known to the resident including dentists, nurses and doctors) to phone the one third of residents who were existing cohealth clients to explain what was happening.
Learnings from the hard lockdown experience informed the development of an ongoing comprehensive model of place-based integrated primary health care and engagement that has subsequently been rolled out to high-rise housing estates across Melbourne. Developed in partnership with local communities and leaders, key features of this model include:
- Health education in place –cohealth has recruited more than 150 ‘health concierges’ to work at the high rise public housing towers to check in on residents’ wellbeing, inform residents of public health messages and restrictions in their own language, link them to local services and supply masks. Health concierges were recruited from the towers and community leaders.
- Early intervention in place – On site testing service including door-to-door testing by clinical staff in partnership with concierges.
- Health care in place – Establishing five primary care clinics on site to service 28 high rise towers with primary health care services and monitoring for all COVID positive patients
- Case management and referral – Telehealth needs assessments are undertaken with residents who have tested positive to COVID-19. Those who have high medical risk are referred to hospital while those with lower health care needs are referred to a GP. Isolation plans and referrals to support services are developed with residents who need to isolate to ensure there are no barriers to them being able to do so.
As a result of adopting this integrated approach that actively engages local communities, COVID-19 outbreaks at other high-rise towers have been prevented and the outbreak in North Melbourne and Flemington has gone from hundreds of COVID-19 cases to now only one case (as at end of September 2020). This model has shown that working with the community can prevent and manage outbreaks, preventing the need for hard lockdowns.
Insights and recommendations
- Culturally appropriate prevention and early intervention actions underscored with strong community engagement are key to supporting vulnerable communities and preventing the need for hard lockdowns.
- Comprehensive scenario planning for high risk settings, such as high-density accommodation, should be undertaken in collaboration with local community health services, leveraging their relationships with residents and community leaders.
- Public health emergency responses should prioritise the mobilisation and leadership role of the health response. Police involvement should support the health effort rather than the other way around.
- Improved data sharing processes are required to allow government agencies to share information with clinicians and health services during a public health emergency.
Melbourne’s lessons – engaging communities is vital
A number of communities face particular challenges during the pandemic, from being able to receive accurate and timely information, to being able to comply with the public health measures designed to reduce the spread of the virus. cohealth acknowledges the proactive approach the government took with some groups, such as providing information in key community languages and swiftly providing accommodation to people sleeping rough.
However, for some other groups the response was slower. As we have seen, people in low paid, insecure work, particularly those not eligible for JobSeeker or JobKeeper payments, for some months had no option but to continue working to receive income. As a result of the fear of loss of all income and long term job loss there have been accounts of people working when symptomatic, not getting tested for COVID-19 or working while waiting for a test result. The introduction of state government payments to support people in these circumstances, such as the Worker Support Payment and the Coronavirus (COVID-19) Test Isolation Payment, is welcome, but could have been introduced earlier.
Effective communication about the risks of COVID-19, public health measures such as physical distancing, masks, hand sanitising, and assistance available for those effected is critical to prevent the spread of COVID-19. Too great a reliance has been placed on distributing these messages via mainstream media, in English, or in a limited number of community languages. Communities for whom these are not the main sources of information did not received targeted and tailored communications until later in the pandemic, and this was often initiated by the communities themselves.
To ensure public health policies consider the needs of, and impacts on, all Victorians, the wide range of communities need to be engaged in both the processes of planning and developing crisis responses, and in the implementation of these responses.
The government engage with diverse communities as active partners in planning for and responding to crises/pandemics.
Melbourne’s lessons – integration and information sharing must be enabled
Health responses to the pandemic at the State level have focussed on the critical areas of testing, tracing, health messaging and preparing and supporting hospitals, and other health providers, to cope with the pandemic.
As the pandemic progressed, it became clear that for those who tested positive there was limited connection to medical care, with GPs not notified of positive test results, or to supports to assist people to self-isolate. This was particularly challenging for people who live alone, or who face barriers to self-isolation (such as low income, living in crowded dwellings, limited information provided in community languages), and was highlighted during the response to the high-rise towers lock down. It became apparent that some people who tested positive were unclear of the requirements to self-isolate, or faced barriers to doing so, while others were not connected to medical care to monitor their symptoms. In normal circumstances the results of medical tests are communicated with the requesting clinician who can then monitor their condition, provide appropriate treatment and make referrals to other medical or social support providers as required. However, positive COVID-19 test results are not generally requested and therefore shared in this manner, preventing the follow up required to monitor patients’ health and wellbeing.
To ensure that all people who test positive for COVID-19 receive care, cohealth, Melbourne Health, the North Western Melbourne Primary Health Network and DHHS partnered to develop an integrated model of primary care, acute hospital care and social support. The pathway is designed to provide safe, high quality care, including community-based care for low risk COVID-19 positive individuals, with escalation mechanisms to higher levels of care if required. This program was piloted in August 2020 and is now being rolled out across Victoria.
In this approach, DHHS provides details of patients who test positive to cohealth. Care Connectors contact patients and undertake a clinical assessment and risk stratification, along with a social and welfare needs assessment. This program has enabled early identification and monitoring of patients who need higher level of health care, including transitions to hospital care when required.
For low risk individuals, information is communicated to the individuals GP, or a referral made to a local GP if they don’t have an existing one, for ongoing health care and monitoring. Medium risk individuals (a very small proportion) are referred to Hospital in the Home and High Risk individuals are referred to hospital.
The pilot program identified that half of the people who have tested positive were provided with social supports to enable isolation. Material needs included evacuation to hotel quarantine where housing was unstable, linking with financial supports and food relief to offset the burden of not working, or assisting people to speak with their employer about not attending work for the necessary time. Care Connectors also provide and clarify vital information about self-isolation processes and requirements, along with mental health support.
In this way, solutions are found for circumstances where people may otherwise have found it difficult to self-isolate, health needs are monitored, and any deterioration is escalated in a timely manner.
Models of care that integrate and coordinate primary health care, hospital care, social support and public health messaging should have local expertise and engagement with community health services across the state.
Recognising the significant health risks faced by people experiencing homelessness from COVID-19, and the potential risks to community health, governments across Australia took rapid action to ensure accommodation was made available for everyone sleeping rough. cohealth applauds the various measures taken by the Victorian Government to provide accommodation and support, including enabling people sleeping rough to move into longer term arrangements such as private rental housing. Many people have been moved from hotel accommodation and into longer term housing as a result. However, for those who remained in hotel accommodation for a longer period of time, this type of accommodation has limitations. Most notably, the lack of cooking facilities and outdoor space make it particularly challenging to remain in these rooms for an extended period of time.
We urge the Victorian Government to build on this work and take action to permanently eliminate homelessness in Victoria through a substantial investment in building social housing and providing wrap around supports for those who need them.
Disturbingly, members of the communities cohealth works with, cohealth staff and the media have all reported increased incidents of racism during COVID-19. These span the spectrum from overt racist attacks to the systemic racism that results in the over policing of particular communities and vital health information not being as available to people with low literacy and from non-English speaking backgrounds as it is to the wider community.
cohealth urges the Victorian government to develop stronger action to prevent and reduce racism in all its forms.
COVID-19 has illuminated the existing inequities in Victoria, and the severe consequences of this for individuals, their families and society more broadly. The health and economic impacts of the pandemic continue to disproportionately effect people facing disadvantage and marginalisation.
The people who are most affected by the disease, and the consequences of the restrictions rightly put in place to limit its spread, are those who are low paid, have insecure work; live in overcrowded, insecure or high-density housing; the elderly; and those with pre-existing complex health conditions. These groups are where the support and investment should be focussed.
cohealth recommends the Victorian Government act to provide a range of financial and practical supports to address the income and housing factors outlined above and therefore reduce the risk of the disease being spread by those who have limited choices. Combined with the Federal Government’s introduction of JobKeeper Payment and the Coronavirus Supplement, these have cushioned the impact. Nevertheless, the gaps in our social protection system have been exacerbated by the pandemic, including:
- people who have not been able to access any income supports due to their visa category, including international students, asylum seekers and temporary migrant;
- people in casual roles who fear losing their jobs if they do not go to work despite being COVID positive. Prohibitions should be put in place for anyone insisting that someone with COVID-19 must go to work or threatening to change the person’s hours or days of work as a result;
- the digital divide – with so many activities of daily life, including shopping, education and socialising moving online, those without the financial resources, reliable internet access or the skills and confidence to use these are becoming increasingly disadvantaged;
- the substantial fines for not complying with public health measures have a proportionately greater impact on those with low incomes. This is a particular concern when health messaging had not reached some people due to literacy or language issues which have not been effectively addressed in communication strategies.
cohealth would welcome the opportunity to provide more information about this submission. Please contact Nicole Bartholomeusz, Chief Executive of cohealth on email@example.com or Jane Stanley, Advocacy and Policy Manager on firstname.lastname@example.org.