Rural Doctors Association of Tasmania

Introduction

RDAT believes overall that the Tasmanian Government be congratulated for the management and control of the COVID-19 outbreak in NW Tasmania. RDAT was first invited to a roundtable discussion with the Health Minister, Health Secretary and various primary health stakeholders on the 14th of March. We think this was timely and a great initiative to share information rapidly and work together across the state. RDAT was able to express the concerns raised in this submission in a timely manner and to the credit of the Tasmanian Government this feedback was taken on board to be actioned. These actions were reviewed at the next roundtable meeting.

However, during the NW outbreak there were concerns from our members and other health care workers about the Government’s response to COVID-19. These are addressed in the Response to the Terms of Reference below.

RDAT believes that the COVID-19 outbreak in the NW exposed the vulnerability of rural and remote communities to pandemics and commends the Tasmanian Government for undertaking this investigation. It will be an important resource to underpin further action to ensure that all Tasmanians have timely access to the health care they need as the COVID-19 pandemic continues and for any future events.

As recently stated by the rural and remote doctors’ national peak body, the Rural Doctors Association of Australia:

Shortcomings of the health system and the way that it operates in rural and remote Australia have been highlighted by the demands placed on it during the COVID-19 response. What is very evident is that many rural communities were ill-prepared to respond to the COVID-19 pandemic (and large-scale disasters, such as the 2019-20 bushfires). The insights afforded by the way in which the COVID-19 pandemic was handled provide a significant opportunity to understand and redress identified issues to ensure that the rural and remote health sector is better prepared for the future.1

Response to Terms of Reference

The Public health and health system preparedness for the outbreak

RDAT expressed concern regarding the preparedness of rural district hospitals, including those associated with the North West Coast COVID-19 outbreak. RDAT members who work in these hospitals/multi-purpose centres experienced poor communication, protocols that were irrelevant to their situation and lack of simulation/practice in dealing with the critically unwell COVID-19 patient. Many members were left wondering what was their role in the statewide response to COVID-19. Many members felt inadequately protected with screening protocols and personal protective equipment (PPE) availability at the district sites.

For example, despite the current governance structure of Primary Health within the Tasmanian Health Service and the management level of Directors of Nursing at the district sites, RDAT members found themselves being the driving force for preparedness and change to adapt their work environment to protect the community and protect health care workers.

Our members were ready to assist in the COVID-19 outbreak but needed further direction and preparation (including resources, staffing measures, PPE, screening policies and patient transfer policies) to feel confident in keeping patients and health care workers safe. RDAT believes that across the NW Coast the lines of management and accountability were unclear.

The public health systems’ response to COVID-19 reflects its overall disaster preparedness. RDAT would like to see better disaster preparedness in rural communities generally, whether this be for bushfires or pandemics and would encourage the state government to work with rural communities to develop robust disaster plans including GPs on the ground, who have the skills and local knowledge to assist.

Aged Care continues to be under prepared in Tasmania and now is under a large spotlight in Victoria due to clusters/outbreaks. RDAT recommends the Department of Health communicates with their colleagues in Victoria and works with the Commonwealth Department of Health to ensure the safety of Aged Care facilities in Tasmania.

The North West Private Hospital was not immune from the outbreak at the NWRH due to staff movement across the two sites. RDAT is of the opinion that the NWPH tends to operate in its own silo with protocols and procedures that are not in parallel with the Tasmanian Health Service and this may continue to compromise care of public patients that are admitted there. RDAT recommends the Tasmanian Health Service and the Department of Health review the protocols and procedures for public patients in private facilities to ensure a consistent standard of care across the state.

The entry and spread of the virus in North-West Tasmania

RDAT believes that the border policies implemented by the Tasmanian Government were/are appropriate and in the best interests of Tasmanians.

However, the continuing use of locums in the North West of Tasmania is a particular concern to RDAT and offers an avenue for COVID-19 to enter undetected and breach our strict border policies. RDAT has continually advocated for innovative workforce solutions such as the Rural Generalist model 2 . The North West Coast of Tasmania is particularly well suited to training and recruiting a workforce of General Practitioners with advanced skills in emergency medicine, internal medicine, mental health, palliative care and more. This model of care focuses on the needs of the community, providing continuity of practitioners and a more cost effective, but safe workforce. This would decrease our reliance on the locum workforce, protect Tasmanians from unnecessary border entries of a high risk (health care worker) population and provide better health outcomes for rural Tasmanians. We believe the Tasmanian Department of Health and the Tasmanian Health Service need to heavily invest in building and recruiting a Rural Generalist workforce, as is the current mandate by the Commonwealth Department of Health through their Stronger Rural Health Strategy.

We also have concerns regarding staff movement between facilities, including low paid casual carers who have little option but to work across multiple sites. It is timely to review staffing and pay structures within our care facilities, to ensure workers are valued for the work they do with contracts ensuring reasonable rates of pay and sick leave so they can take time off when needed.

The efficacy of decisions and actions, with respect to identification, isolation, contact tracing and quarantine for cases or potential cases in the North-West

The main shortfall of the COVID-19 response in the NW was the lack of preparation for staff illness/diagnosis with COVID-19. The ability to contact trace staff and patients was severely hindered by the reliance on paper records, paper rosters, paper shift changes and itinerant staff that worked over multiple wards or health system areas. RDAT members experienced poor coordination of contact tracing by not being notified of their close contacts with positive cases. It was clear from early April that the extent of illness in the NWRH was not contained and that traditional contact tracing methods had escaped usefulness. RDAT recommends that the Tasmanian Health Service updates its HR systems to include online rostering and timesheets, identification of staff movements through swipe card activation and systems to account for staff that move between hospitals, wards or health service areas (e.g. the community). RDAT also recommends that more staff be available for contact tracing rather than the few select nursing managers that had to spend numerous hours per day calling and collating interviews, preventing them from dealing with other aspects of hospital management.

The decision to close the NWRH provided an opportunity contain an invisible disease. However, the impact on the local community was major. Patients were forced to seek care from further afield at the Launceston General Hospital. This caused major disruption of normal communication and clinical care across the NW Coast from Primary care to hospital. For example: referrals from the LGH back to NW Health Services went missing or were lost due to incorrect fax numbers, inability to find the correct service or in some cases no communication from the LGH at all. Lack of timely discharge summaries from the LGH is a chronic issue that the THS needs to address. RDAT recommends that the Tasmanian Health Service adopt a central referral hub to keep contacts up to date and use eReferral processes that give the referer an acknowledgement that the referral has been received.

RDAT takes this opportunity to thank local GPs on the NW Coast who over the Easter period opened their private General Practices to provide care not available in the public hospital emergency departments.

RDAT is a staunch advocate of utilising GPs with advanced skills in the local community and recommends the Tasmanian Health Service keep a register of GPs with advanced skills who can service departments in the hospital in the event of a severe workforce shortage from illness or quarantine. For example: local GPs with advanced skills in Emergency and familiarity with local health resources, may have prevented the need for the Australian Defence Force AUSMAT team needing deployment to Tasmania. Future preparation plans need to consider that the AUSMAT team may be unavailable for deployment in a critical service disruption

Timelines and effectiveness of communications to hospital staff, the local community and private sector health service providers

RDAT acknowledges the changing nature of the pandemic, including new case definitions, epidemiological risk factors and new case identification. RDAT congratulates the Tasmanian Government for bringing together primary care stakeholders in a weekly teleconference. However, RDAT members raised concerns about communication from their direct line managers and the broader Public Health response. RDAT members were concerned that they were directed to watch public broadcasts/media conferences to learn intricate details of the COVID-19 outbreak and the closure of the NWRH.

RDAT is concerned about the mental health impacts on staff of the NW Coast outbreak. With a recent case diagnosed again at the NWRH (10/08/2020) RDAT members expect to see an increase in anxiety and trauma related presentations to General Practice. Members have also seen a level of chronic stress and anxiety in the general public that is destabilising the mental health of the population. RDAT recommends that the Tasmanian Government proactively enacts a mental health policy that improves access to funded psychologists and other trained mental health workers for the general community.

Access to, training for and use of Personal Protective Equipment.

RDAT reflects on the comments of the Rural Doctors Association of Australia 3 and endorses them in the Tasmanian context:

In rural and remote areas, PPE shortages were acutely felt and anxiety about the impact of travel restrictions on the supply chain added to stress. The performance of Primary Health Networks (PHNs) as a distribution mechanism for PPE from the National Medical Stockpile was not uniform across the country and in some cases has been described as “terrible”. General practices in many rural and remote areas operate as small businesses and do not have the purchasing power of larger organisations. This was, and continues to be, a significant risk for rural and remote doctors and their teams responding to the COVID-19 pandemic. Critical items of PPE such as disposable gowns, face shields, and even gloves were either unavailable or their delivery date was not guaranteed – or worse that single use products such as isolation gowns priced at $2.80 per item prior to the pandemic response were being sold for as high as $17.00 per item. That prices are higher as a result of the laws of supply and demand, the impact of restrictions on transport, and other factors is not unexpected. However, the critical issue for rural doctors is that even when sufficient PPE became available, the cost of protecting themselves and their staff had greatly increased. This remains a concern. The decision to restrict domestic travel meant that regional airlines and intra- and inter-state bus travel either ceased or was significantly reduced. This has caused great disruption not only to medical freight arrangements and costs, but also to timely pathology testing. While testing in capital cities has a 24-72-hour turnaround, for many rural and regional towns it is 7-10 days as it takes 3-5 days for the specimen to be collected and transported.

Reports from our members in the early days of the pandemic regarding PPE included:

• They were discouraged from wearing surgical level masks in clinical areas due to ‘scaring patients’
• They found that on the wards (on the floor) there was a limited amount of PPE available and had to ask the operations manager for the shift for more e.g. 3-5 surgical masks available on a ward at time.
• They found that after hours there was difficulty restocking PPE supplies with after-hours managers not having correct access/keys to storage rooms
• They felt that their safety was being compromised and PPE use discouraged due to a perceived lack of supply in the Tasmanian Health Service
• Members in General Practice were only able to obtain surgical level masks from the National Stockpile via Primary Health Tasmania o This is only part of the total PPE required to see respiratory patients – other items include gloves, gowns, facemasks and disinfection wipes
• Stock levels of PPE was inconsistent across hospitals, and even within departments

PPE utilisation (e.g. contact vs droplet vs airborne precautions) was inconsistent across hospitals, and even within departments

RDAT is concerned that training of PPE was undertaken after the NWRH outbreak and ‘fit-testing’ of masks in not routinely offered to staff

RDAT recommends a consistent approach to PPE ordering, supply, protocols and training across all health care settings in Tasmania. Aged care and General Practice are particularly vulnerable as seen in the latest Victorian COVID-19 outbreaks/clusters. Whilst normally not within the remit of the State Government, RDAT encourages the Department of Health to consider training, protocols, and supply of PPE to private health care entities such as a General Practice and Aged Care. We are only as strong as our weakest link in COVID-19.

Recommendations

• Maintain an open and honest line of communication with health care workers in Tasmania by:
  • a. Regular Primary Health update meetings with relevant stakeholders
  • b. Clear communication and feedback mechanisms for every health care worker to raise concerns or ask questions
• Include rural district hospitals and their staff in COVID-19 planning and preparedness.
• Maintain a local workforce mix of specialists and generalists that meets the needs of the local community and reduces reliance on locums entering the state.
• Improve the integration of rural district hospitals, rural general practices and Rural Generalists in disaster planning for the state of Tasmania.
• Learn from interstate outbreaks to plan proper procedures and protocols in the Aged Care system to prevent widespread deaths and health care worker infections.
• Coordinate, supply and provide protocols for correct PPE usage and safety measures in all health care facilities in Tasmania.
• Prepare and undertake increased resourcing for mental health presentation in Tasmania related to the COVID-19 pandemic.

Footnotes

1 RDAA Submission to the Senate Select Committee COVID-19 Inquiry, available: https://www.rdaa.com.au/documents/item/1161

2 RDAT and RDAA Workforce Plan for Mersey Community Hospital 2017, available: https://www.rdaa.com.au/documents/item/57

3 RDAA Submission to the Senate Select Committee COVID-19 Inquiry, available: https://www.rdaa.com.au/documents/item/1161