Stay home, stay safe? Public health assumptions about how we live with COVID

ABSTRACT

The COVID pandemic has had an uneven impact on families and communities, exacerbating existing structural disadvantage. We demonstrate that the construction of the pandemic by policymakers as primarily a medical problem has shaped the public health response in such a way as to hide the resulting lack of access to necessities for many and deterioration in people’s wellbeing. We interviewed social welfare service providers in an urban area of high cultural and linguistic diversity and low socioeconomic advantage, about their experiences in the 2021 lockdown period. Our findings highlight the unanticipated impacts of the public health response on people who cannot be recognised in the normative subjects constructed by policy. We bring to the fore the hidden experiences behind the government-reported COVID health statistics and explore the (dis)integration of services that support survival. To avoid worsening structural disadvantage, policy responses to crisis require conceptualising the problem and its solutions from diverse standpoints, built on an understanding of the different elements that shape who we are and the way we live.

KEYWORDS:

• COVID
• policy
• service integration
• psychosocial
• structural disadvantage
• biopsychosocial

Introduction

Like most of the rest of the world, the COVID pandemic emerged in Australia in early 2020. Sydney experienced restrictions on social gatherings from March 2020, with the first period of ‘lockdown’ from June 2020. Following the emergence of the Delta COVID variant, further restrictions were imposed on areas with high prevalence rates. Some areas of Greater Western Sydney were particularly affected, with tighter stay-at-home orders in place from July 2021. Vaccination rates across the state increased significantly between May and October 2021, resulting in the easing of restrictions. Then the Omicron variant caused a new wave of infections. Positive cases continued through 2022, rising and falling in response to new variants.

The way that a problem is constructed determines the policy response (Bacchi & Goodwin, 2016). The Australian government saw the pandemic as a health crisis that would severely impact the economy, and so focussed on public health measures and economic recovery (Andrew et al., 2020). Rapid changes in policy and practices were instigated, including public health measures of border control, boosting the capacity of the health system, the prioritising of online service delivery (James et al., 2021), social distancing, and changes to welfare payments and taxation (Andrew et al., 2020). Additional COVID-19 welfare payments reduced financial and mental stress for those who were eligible (Botha et al., 2022).

Examining these policy responses from a poststructuralist theoretical orientation, using the What’s the problem represented to be? (WPR) approach (Bacchi & Goodwin, 2016), allows us to make visible the assumptions that underlie the policy response, and the lived experience of the effect of the problem representation.

An emerging body of research has shown that the pandemic was not solely a public health crisis with economic consequences but also a social phenomenon with both financial and wellbeing effects that varied depending on existing social structures and inequalities (Fallon et al., 2020). For example, people living with disability are more vulnerable to pandemics (Colon-Cabrera et al., 2021). Cycles of care within families and households take shape and shift over space and time (Harding et al., 2017). The pandemic disrupted these cycles, removed caring supports by confining people to their home so that they could not visit other households to care for extended family, and disrupted paid in-home support. This disruption exposed the assumptions of social and political constructs that determine whose care needs should be met and by whom. The unpaid work of housework, household management, and caring for children, elderly, sick and family members living with disability increased in Australia, particularly for women (Craig & Churchill, 2021). Women of colour and those who were single parents were disproportionately impacted by the lockdowns (Friedman & Satterthwaite, 2021).

During periods of the pandemic, schools moved to online learning delivery, with the vast majority of students at home. The impact on student achievement levels was most evident in geographical areas of disadvantage (Gore et al., 2020). More concerningly, both student and teacher wellbeing were substantially impacted; with an increase in teacher, parent and student stress and anxiety, particularly for those with limited access to technology or low levels of digital literacy. The inability of teachers to check in with vulnerable students contributed to teachers’ anxiety (Gore et al., 2020). A study of parent experiences of home learning during COVID-19 found that households living with disadvantage were less well equipped, materially and psychologically, for home learning (Sanrey et al., 2021). This study is likely to have underestimated the impact of disadvantage because the data were collected online, effectively excluding those without access to technology, who were most negatively impacted by the requirement for home learning. Oppermann et al. (2021) found that when parent stress levels increased, there was an exponential decline in home learning activities for preschool children. Areas of high cultural and linguistic diversity were particularly negatively affected by COVID (Voola, 2021). This is unsurprising given ‘the privileged subject position, structural location or cultural practices’ of Anglo-centric whiteness in Australia (Moreton-Robinson, 2004, p. vii). In contrast to other Australians, people from culturally and linguistically diverse communities in Western Sydney reported fewer positive effects arising from the pandemic (Cornell et al., 2022). Another survey of culturally and linguistically diverse people in Western Sydney (Mude et al., 2021) found that the worst impact was on people’s perceived safety, then access to social support and social services, and then their financial situation. The circulation of accurate, trusted and reliable information is vital in a pandemic (Abbas, 2021). Many people in Australia had difficulty accessing easy-to-understand COVID-related information, with different experiences across different language groups (Ayre et al., 2022).

A study of the response to COVID in one Local Health District in Sydney concluded that the response had been swift and effective, reaching marginalised populations, reducing the transmission of COVID and the number of people falling sick (Liu et al., 2022). However, the outcomes are identified as minimising the number of people who are infected or sick with COVID-19; minimising deaths from COVID-19; reducing the burden on the health system; and delivery of vaccination. The model of care under review was a medical health model, based on narrow COVID-related health care. Whilst concern was noted that other aspects of care that fell outside of this definition were ‘neglected’ (p.7), this concern was brushed aside. Overall, the response was judged to ‘effectively work within and across sectors in a people-centred manner’ (p.1). An example of neglected aspects of care is food insecurity, which increased in Australia during the pandemic, with two new groups affected being those newly unemployed and international students (Louie et al., 2022). Food insecurity results in more than a 250% increase in depression and anxiety (Fang et al., 2021). A second example is the finding that lockdowns led to an increase in reported domestic violence (Pfitzner et al., 2022).

Existing research demonstrates that the impact of COVID has been uneven, often exacerbating existing structural disadvantage. This paper examines how public health policy responses have contributed to these negative impacts for some communities. Improved policy responses require conceptualising the problem in different ways, from diverse standpoints. We present the perspectives of service providers in an area of high cultural and linguistic diversity and socioeconomic disadvantage, where families may not be proficient in English, and have restricted access to technology. These perspectives illuminate the construction of the normative subject in the policy responses and the impact on families that do not fit this norm.

Methods

This research takes a post-structuralist approach to examine how the problem of COVID was represented, and the assumptions that underpin the policy response, through analysing data gathered from service providers in an area within Greater Western Sydney, about their experiences supporting households during the COVID pandemic. We collected data through interviews and focus groups. Research ethics approval was obtained through Western Sydney University, approval number H14726.

One member of the research team interviewed a total of 27 people via six focus groups comprising between two and nine participants and four individual interviews. Thirteen participants were from a Local Health District (LHD) COVID response team, comprising four Aboriginal health workers and nine social workers. Fourteen participants were employed by the regional branch of a large non-government organisation (NGO): 3 worked primarily in a management or supervisory role, 11 were frontline workers. All but one of the participants were women, the other a man. To protect confidentiality within a close-knit network, when we attribute quotes, we shall describe our participants as either from the NGO or the LHD.

The interviews were semi-structured, guided by questions about the impact of COVID-19 and the associated restrictions on clients and services; what new needs, problems or clients emerged; and how services coped and adapted. Two members of the research team analysed the data. The analytic approach involved an iterative cycle of individual coding, discussion and code comparison, and then refining the analysis by writing (Neale, 2016). In our analysis, the policy includes text, symbols, ceremony and other mechanisms of government (Bacchi & Goodwin, 2016).

Findings and discussion

We discuss our findings in three sections. The first brings to light the lived experience behind the case numbers; the second explores the construction of the COVID citizen, and how they were assumed to live. These demonstrate that the effects of the pandemic were unequal because they were refracted through existing social structures, and the government response privileged normative Anglo-centric, well-resourced households. In the third section, we consider how people had to work against the system to address the inequities, where policy contributed to service (dis)integration.

The hidden experiences behind the numbers

Each day, from June to September 2021, during the period of greatest public health restrictions, the Premier and the Minister for Health held a press conference at 11 am. The daily rates of infections, deaths and vaccination rates were reported, and changes to restrictions introduced. This press conference functioned as a policy ‘ceremony’ to define the ‘problem representation’ as biomedical (Bacchi & Goodwin, 2016). One participant expressed frustration that the briefings provided these numbers but did not recognise other significant impacts of the public health measures and the pandemic:

So, you would hear somebody died, but you wouldn't hear everything that went with that … Brad Hazzard [the Minister for Health] would get up [at the daily press conference] and say, ‘Oh the Health system is struggling, but it's coping’, but they actually didn't really understand the depth of the complexity to the piece of work. (LHD)

Our research participants were frontline workers who witnessed first-hand the scale of the problems created by the lockdowns within a system that was driven by a biomedical health response and ignored other health needs.

The Health system had factored in a medical response to COVID. So, they had a system where if you had COVID, you got a phone call twice a day to check your symptoms. And then as you escalated then your management would change, but nobody had really factored in how significantly the impact of COVID would be of people psychosocially. (LHD)

Whilst we do not dispute the need for a clear public health program of infection control and vaccination, we argue that there was also a broad range of other health-threatening, and sometimes life-threatening, issues that people faced, that were exacerbated or directly caused by prioritising a biomedical health response without due consideration of the impacts.

Our participants were fielding calls for support from the public that fell outside of the health department response. The volume of these calls was overwhelming: ‘if we would hear that there were 10,000 COVID cases, we knew that that was going to at least translate to 100 referrals for us for the day.’ (LHD) These referrals evidenced a lack of access to basics like food, medication, clean homes, and someone to talk to. The daily reports of hospital admissions hid the impacts on people who were undertaking caring roles for family and loved ones in the home. We heard the story of one woman who

was a full-time carer for her two parents that had dementia … , and also a whole variety of complex health issues on top of that. She was COVID positive, and she was in an apartment building … and trying to still fulfil her carer duties while not trying to put her 90-year-old parents at risk of getting COVID. And the emotional side was that fear of getting them sick and being responsible for the worst-case scenario of death was what she was talking about with me. (LHD)

For some who required personal care and assistance, the lockdowns meant being left with uncertainty about when help would come to support bathing, toileting, getting in and out of bed, meal preparation and feeding.

Access to food was a concern for many people during the lockdowns.

We had grown men on the phone crying because they were so thankful that we were going to bring food out because they were days without food. So, it was really tough. (LHD)

The government made provision for people to access emergency food hampers, but there were waiting times of ‘up to three days for it to get to your door’ (NGO). Some children were accustomed to being fed each morning at breakfast clubs at school, which ceased operating when schools closed. Food security was an issue for many vulnerable families prior to the pandemic, and the situation worsened during the lockdown.

Some of the workers we spoke to who delivered food hampers described it as an overwhelming task that proved to be much greater than simply delivering hampers. There were occasions where workers would phone to confirm details to deliver a food hamper only to find that a medical condition had escalated, and an ambulance was needed. Workers found that they were having to respond to wide ranging and complex problems. These included removing waste from crowded apartments, delivering baby formula, negotiating with Centrelink for income payments, and translating basic information into Arabic and Vietnamese. They also met health-related needs such as sourcing prescription medication and basic medication such as Panadol, providing pulse oximeters, and calling ambulances.

Participants explained that there was a cumulative effect on people of multiple lockdowns in consecutive years. The impact of the second lockdown was much worse because the first lockdown had depleted reserves and created complex problems from which households were taking time to recover. The discontinuation of some services in 2021, for example, for people who were homeless, added to the strain on workers and service users. The majority of requests for support were from new service users, who had never needed to access support from agencies before. The sharp influx of new clients reduced the time and resources available for existing clients. Many of the workers we spoke to had been moved to a COVID response team, or the nature of the referrals they were now receiving meant that they were responding to new, COVID-related referrals of a demographic that they did not usually see. For example, a social worker who usually worked with Aboriginal parents with new babies, now responded to households of elderly people, or young single people, or homeless adults.

The participants in this study expressed concern that the volume of new service users, combined with the restrictions on visiting clients face-to-face, significantly diminished the level of care it was possible to provide to existing clients:

We had a family on one of our Child and Family Health nursing programs. This young baby under 12 months had significant developmental concerns. … [We were not] able to go in and implement activities from a Child and Family Health nursing perspective. When we were eventually able to go out and sight this child again their global development had significantly deteriorated to the point that they then had to be referred to the Paediatric Allied Health Unit for support. (LHD)

This example demonstrates the risk of having to deprioritise existing clients. Some staff dealt with this by keeping in touch with their existing clients, attempting to create and maintain a relationship until they could resume their usual work with them.

Participants’ expertise in working with families gave them a whole of family wellbeing perspective on the impact of COVID restrictions. One way of supporting wellbeing was by delivering craft packs and games:

what we were doing is getting craft packs delivered to families from Big W, that same day delivery, games, board games … all that other stuff for the kids that nobody would ask for. (NGO)

Another was organising interactive activities:

We had little competitions with families where … I think it was called … Lockdown Countdown … We did it a couple of times where we would give them almost like a scavenger hunt of things to do, and then they would send us photos of them and the kids doing stuff … So that was really fun. (NGO)

Others have identified that making art with children was important in response to COVID (Armstrong & Ross, 2021).

One participant noted that it was easier to get permission to leave lockdown restrictions for medical appointments than for activities to support good mental health:

a lot of my requests [to visit families were] declined because the priority was the child's health and the mum's health rather than their - I guess mental health is harder to show. If they were missing hospital appointments then I was able to pick them up, drive them there. But if it was a matter of them being isolated and breaking down, that was a lot harder to get approval for. (LHD)

This is a clear indication of biomedical needs being prioritised over psychosocial needs.

Despite decades of effort to broaden health approaches to a biopsychosocial model (Wade & Halligan, 2017), COVID was framed narrowly as a biomedical problem, of infection and death. The evaluation of the COVID response has focussed on biomedical outcomes (Liu et al., 2022). This problem representation has resulted in a lack of care for the overall health and wellbeing of many people.

The COVID subject and the way we live

The public health response made assumptions about how people in NSW live based on Anglo-normative, middle-class and ableist assumptions and values. As one participant noted, many families ‘don't have the financial resources to be able to have some of that stuff stored in bulk … bulk meat, bulk of anything really. A lot of people live pay-check to pay-check’ (NGO), whilst others ‘really only just make things happen day by day’ (NGO). The normative assumption that people had a safety net of savings they could readily access in hard times did not hold.

One young fellow was ringing. He'd lost his job. He had no money, so he was ringing Centrelink to try and get on. He was on hold for five hours then his data ran out. That's it. End of his data, so he can't ring back again. How's he going to get money? (NGO)

Whilst families in higher socioeconomic areas would likely have access to savings or family members they could call on, this was not the case for many households in this area.

Accessing food online became essential during the lockdowns. This required the means and the capacity to shop online.

My clients did not have credit cards. They wouldn't be approved for a credit card. A lot of them hadn't been able to keep down full time work. They were escaping domestic violence. Just a lot of challenges. A lot of literacy issues, no internet at home. Old phones. Very old phones. (LHD)

For those who were able to place a food order online, supermarkets were not able to keep up with demand, resulting in people waiting days for food to be delivered. At the height of the Delta wave of infections:

if I ordered it today, the soonest I could select a date was eight days away. Yeah, keeping in mind, these families are under immense pressure and stress. They're losing their business, their minds aren’t super clear going, ‘Right, so I know this is going to happen in eight days, I need to now start to plan my delivery.’ That's not how families live. I'm not that organized! (NGO)

Participants said a lot of time went to assisting clients to access food through online sources that were only in English, because ‘if you couldn't read and write using English, you actually couldn't do an online order for Woolworths’ (LHD). Inadequate technology amplified the difficulties of home schooling:

we had kids trying to do home schooling on a phone, one phone, all the family. Like that's impossible. … service providers, government would say, ‘Just buy them a laptop’, but it's not the laptop. You also need the data plans that go with it, access to the Internet. So, then getting all of that was a big issue and then still even with all of that, you're purchasing perhaps one laptop per family. There might be four or five kids trying to home school. How do they all get into their own Zoom classrooms on the one laptop? (NGO)

Access to technology and credit were pre-requisites for online food shopping, and many households had neither. Lack of access to digital technology made school inaccessible for many children.

The provision of hampers was also underpinned by normative expectations. The assumptions about how we live, how a household is constituted, and what we eat, had implications for a whole range of people in situations for which the hampers were inappropriate or inadequate. For example, the quantity of food was insufficient for large households in isolation for the required 14 days. We heard ‘you also only got one [hamper]. … Doesn't matter how many people are in your household’ (NGO), and ‘our families are multi-generational families, … and they needed far more food because we can have upwards of six people living in a household’ (NGO). Hampers were structured for nuclear families of two parents and two or three children, rather than those who live in extended families.

The lack of culturally appropriate food was an added threat to food security. Many households in the region did not usually shop at the major supermarket chains, which were the primary providers of online shopping. Rather, households shopped at their local stores, with culturally familiar foods that were not available online. This lack of culturally appropriate access to food was compounded by the restricted, Anglo staples of tinned spaghetti and tinned tuna in the food hampers: ‘there was not one culturally appropriate thing in those hampers’ (NGO). Health workers delivering food were sometimes faced with the complex task of trying to describe how to make a meal to families who were unfamiliar with the hamper’s contents.

Those with dietary requirements were not served well by the hampers: ‘it didn't cater for people who were gluten intolerant, diabetic, or [had a] heart condition’ (NGO) Some participants commented that the hampers did not include fresh fruit and vegetables, both of which were recommended for people recovering from COVID.

Rubbish built up in people’s living space. One participant explained:

the government brought in the restrictions that said if you lived in an apartment that you were not allowed to access any common property, so you literally cannot leave your apartment door, … So, the bins and the basements were common [property]. And so, then we had all these other issues, so we had nappies, nappies building up. (NGO)

The decision to restrict people to their homes assumed that they were able to place waste outside for collection, without leaving their private property, which is the case for houses but not apartments. This resulted in a loss of basic sanitation for people living in small and/or overcrowded apartments.

Many people do not live in houses or apartments, but instead seek shelter where they can. For some their car is their home. Providing assistance to COVID-affected people in these instances was a major undertaking and demonstrates the vulnerability of people living without proper shelter.

I had one couple that were like in their 50s. They’d been living in a car, they got COVID, so they had to get into a flat, but they had nothing, so we bought them a fridge, and then got them some food and some cooking things so that they could actually, you know, live. (NGO)

In another case of two people living in a car, one was taken to intensive care and the other to a health quarantine hotel. The housing crisis in NSW pre-dated the pandemic. Home is not necessarily a safe place for many families due to family and domestic violence, drug use or child abuse. In the words of one participant: ‘What happens when home is not safe, but then the government says you're locked in that home for four months?’ (NGO) The lockdown conditions meant that the option to flee to seek safety outside the home was made more difficult.

Those who had limited literacy in English had restricted access to information, particularly the text of the policy response available online. The 11 am COVID updates provided many people with the latest details of lockdown restrictions. However, rather than rely on English language media,

non-English speaking people may be going to mosques and they're hearing important messages from their leaders and, or, whether it be a church or whatever it might be, or just any gathering, like of cultures that come together . . .. But we took that away from people during COVID. And it just wasn't thought about, well, how are we going to get these messages out now if they're not able to get them from their leaders or their fellow parishioners, or whatever it might have been. So, I think it was probably lack of insight, maybe that people just didn't think, ‘well, it's clearly a language barrier and we've taken away that. How are we going replace that?’ (NGO)

The limitations of the effectiveness of policy communication in English led to other government mechanisms coming into play. These were police fines and an army presence:

We're all aware of helicopters and patrols and the army, and no other area faced that discrimination. And specifically, it’s a very multicultural area with a lot of people from war-torn countries with trauma history. It didn’t sit well with most of our team. Because people we'd been meeting [were] telling us that there's the army knocking on the door or another helicopter going past. (NGO)

One participant suggested that ‘if you want them to stay locked in, don't send the police. Or the army. Get them the right food, then they won't need to leave the house’ (NGO), highlighting that a different response was possible.

Many of the participants in our study were required to work from home, sometimes under stressful and challenging conditions. Some noted that this was not an option for many of the people seeking their help.

The employment in that area, none of it is transferable to work from home - it's very factory based, it's shop-based, it’s own-business based. It's not like you and me. We just pick up our laptop, go home and start working. They don't have that option. (NGO)

This quote identifies another group who were disproportionately disadvantaged by the lockdowns. They were families whose businesses and places of work were forced to close on short notice, for an unknown period. In many cases, these businesses’ operations could not be transferred to working-from-home environments. The government public health response made assumptions about standards of housing, and conditions of employment. These included that people had a home for shelter, with space for self-isolation, leisure and work.

Service (dis) integration

The circumstances of the lockdown created a sudden disruption in the existing patterns of care provision, creating a new and uncharted legal, social and political environment (Harding et al., 2017). ‘[The government] were paralysed by the enormity of how quickly [this location] went under’ (NGO). Social services agencies were able to see the hidden impact of the pandemic on care work, and the disintegration of care provision. We have provided evidence of this disruption in food supply, home support, education, disability support and income support. Our interviewees gave examples of attempts to work in an integrated way with services, but these were often ad hoc.

The impact of paid carers ceasing home visits was a significant crisis for people who were reliant on assistant with all the daily living tasks.

A number of people who hadn't been showered in days. Their catheter needed to be changed. Like really serious health implications for people who couldn't get into the shower themselves or had zero mobility and relied on people. So, in terms of … and I don't wanna get too graphic, but people soiling themselves in bed because usually they have someone come to the home to take them to the toilet and that kind of thing. That really came to a standstill. (LHD)

The agencies that provided these services for older people and people with disability could not enter people’s homes to provide care.

These cases were so outside of any anything that we've ever had before, and then there was there a real shirking of responsibility around who actually owned the responsibility of these clients because yes, they have disability. So yes, their disability meant that their care was difficult to manage, but if they didn't have COVID their care wouldn't be as difficult to manage despite their disability. So that it was like, well, who needs to pay? Is it the NDIS? Is it Health? Is it COVID or is it the disability? (LHD)

The cessation of this care, combined with confusion around sector responsibility, is an example of the ‘biopolitics of disability’ that resulted in systemic inequality in the COVID response (Goggin & Ellis, 2020).

The speed of the impact of the disruption to care cycles and service delivery gave the service system little time to evolve a response.

What we saw was a struggle for government departments because there are so many layers of bureaucracy to get through to get approval before they can get to the Minister to go, ‘Oh yeah, that sounds like a good idea.’ (NGO)

The disruption meant not only that processes and systems that had been set up to support care did not function anymore, but also that new and existing policies served to hinder rather than support a collaborative service response. Participants provided examples of acts of resistance to work around unhelpful rules and protocols. For example, quantity restrictions on purchasing formula created significant challenge and distress for families who used formula to feed their babies. To provide formula to families, participants drove from pharmacy to pharmacy buying small quantities in each. In another example, protocols for translating information meant that only approved translators could be used, and the turnaround time for this was weeks. People needed information immediately to be able to order food online and comply with health regulations. Multilingual NGO staff took the initiative and translated material into the two most common community languages. Eventually health officials agreed, ‘they said, “Alright, just pop them in [to the food hampers].” But we were gonna do it anyway.’ (NGO)

The COVID policy response did evolve. We were provided with examples of cross-agency collaboration, where clients’ needs were understood, and responded to. Before the lockdown, funding criteria stipulated who could receive certain support services. During the pandemic, service providers found themselves ignoring rigid criteria to provide a response based on need. One worker explained that there was good cross-agency communication in their area, citing this example:

if you were a carer of someone, [or] people who were pregnant or had a young one, then they were considered someone who required assistance because it was too risky for them to go out and go shopping themselves or to do that. So that's what I always told my clients. So, there's a panel that happens especially for the [area I work in] and they have a police officer on the panel. And so that was one of the early questions that came up and he guaranteed. And then he said, like, if there's any issues and then we could refer them, the other people to him. So that was the way that we got around it. (LHD)

The officer undertook that the police would not take punitive action against people who broke lockdown restrictions to provide this care. This collaboration supported flexibility, and practical interpretations of restrictions that would otherwise be barriers.

A major problem faced by people who lost their income was accessing financial support from Centrelink, the federal agency responsible for welfare payments. Whilst the federal government provided extra funds that could be applied for in several ways, the bureaucracy required to get an application approved, especially for people who had never been in the Centrelink systems before, was for some impossible. Our participants reported that Centrelink staff were not resourced to manage the volume of calls, and people were on hold for many hours. We were told that Centrelink staff often did not have up-to-date information to provide advice, resulting in people being told to call again and ask for a different department, ‘so, you just kind of went round and round’ (NGO). Social workers tried to address this problem by creating three-party telephone conversations between themselves, applicants and Centrelink staff. ‘So that worked for a little while and then Centrelink decided that they had a problem with that because it was a breach of privacy and wouldn't do it’ (NGO). In this example, flexible collaboration foundered. Many schools in the UK worked within multiagency networks including police, hospital emergency departments, and social workers during the pandemic to monitor the welfare of vulnerable students and provide support, including food supplies (Baginsky & Manthorpe, 2022). This level of multiagency response was not reported by our participants.

Participants were involved in advocacy work to instigate service collaboration. An example is a collaboration formed with Ambulance NSW, resulting in a change to practice so that when parents and carers were taken to hospital, an ambulance officer would stay with unattended children until social workers could arrange care. There was negotiation with other statutory bodies as to where the responsibility for care lay in some circumstances. Cross-agency collaboration was also developed in an ad hoc, informal manner, with staff developing networks between services by trial and error.

We would have [a staff member] that would be ringing up [another service] and they would get on to someone, and then they’d pass their number around because they were really helpful. So, there was someone in Housing, there was someone in Centrelink, there was someone in Service NSW, or we had a person here that had a liaison with Service NSW, … [or] Health. We had that connection with them. We had those people we could actually ring straight through to. (NGO)

Some people were in a position where they felt able to exercise agency and solve problems.

[We had] a very big authorising environment from our Board and Directors to say, ‘you do what you need to service that community.’ So they took on a fair bit of that risk to go … to trust us to say, ‘You manage it how you think.’ … . (NGO)

Not everyone felt so empowered:

I feel like there was there wasn't enough consultation. … being told what we needed to do just meant that we're getting one person's perspective instead of the … collective perspectives of all the people on the ground doing the work, who could have probably come up with a better strategy that worked better for the programme and for our clients. (LHD)

The pandemic required a level of service innovation, integration and collaboration, at speed, and for a long period, in areas such as identification of needs, case management, funding and procurement.

Several studies show that the effective operation of service systems is crucial to supporting vulnerable people, and to economic and social recovery. For example, organisational networks within social service provision were important in operationalising effective responses to the crisis, as was innovation (Belso-Martínez et al., 2020), and wider participation from employees and other stakeholders in organisational decision making (Child, 2021). Like others, we found that it can be challenging for social workers to operate in an integrated way with health systems due to the power imbalance caused by the dominance of the biomedical model (Ashcroft & Van Katwyk, 2016). Integrated service response is critical to the provision of appropriate support and requires shared vision and values, horizontal and vertical networks, self-efficacy of the service deliverers, and formalised processes for interagency communication (Schmied et al., 2010). Models of flexible integrated service provision are ideally developed and nurtured in usual practice, ready to be mobilised during times of collective crisis. The crisis is not over, and this service integration needs to be ongoing.

Conclusion

We argue that the construction of the pandemic as a biomedical problem, of prevention of infection and death, resulted in policy predicated on the assertion that if people stayed at home, the virus would not be transmitted, and they would be safe. Whilst a biomedical health response was necessary, this policy focus hid the problem it then created, of lack of access to food and money, and psychosocial impacts of the pandemic. The effects of the pandemic were unequal because they were refracted through pre-existing inequalities in social structures, exacerbated by normative Anglo-centric and middle-class assumptions about people’s ability to cope. The normative subject of COVID policy spoke English, had access to credit, technology, spacious housing and flexible employment.

People and services did the best they could, and more, in a volatile, dangerous environment where not enough was known about the COVID virus. However, representing the problem as more than biomedical, and thinking beyond the normative construction of the way that people live and the resources they can access, is vital in a public health response to crisis, and requires an integrated service response. The service system took some time to adapt to the breadth and depth of these impacts of implementing the policy. The COVID pandemic has had complex hidden effects on a significant proportion of households, effects that will be felt for years to come.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by Uniting NSW ACT.