A total of 15,487 residential care and nursing homes are registered with the Care Quality Commission (CQC), and have around 410 000 residents. Almost half of newly admitted residents come from hospitals. With the UK holding the European record for numbers of deaths from COVID-19 it is worth noting that 20,000 of these occurred in care homes. While a pandemic planning exercise in 2018 warned about the danger of cross infection by care staff, there were no measures put in place to prevent this. On 2nd April, the Government issued advice that included “ . . . the care sector also plays a vital role in accepting patients as they are discharged from hospital . . . . because hospitals need to have enough beds to treat acutely sick patients. . . . Some of these patients may have COVID-19, whether symptomatic or asymptomatic. All of these patients can be safely cared for in a care home . ”
Many now question the wisdom of this directive. A survey by the Alzheimer’s Society found that homes frequently felt completely unsupported and two thirds were unable to effectively isolate patients carrying the virus. In addition, many frail, elderly patients were discharged to their own homes with social care support. Hard pressed community care workers with inadequate PPE and on zero hours contracts were likely to have spread infection as well as suffering an excess of deaths themselves – however low testing rates and government failure to record deaths of people supported in their own homes mean there is no way to verify number of deaths. The government’s Scientific Advisory Group for Emergencies discussed care homes only twice in the first five months of 2020 and had no discussion relating to people discharged to their own homes with a package of community care support. The prime minister chose to point the finger of blame for deaths at care home managers, with Boris Johnson stating: “Care homes didn’t really follow the procedures in the way they could have”. The fact there were no such procedures did not seem to trouble him. Richard Horton, editor of The Lancet, considers that one of the lasting legacies of COVID-19 will be the silent human destruction wreaked on the most unprotected members of society, with devastation in the social care system taking place without any politician admitting to knowing or understanding what was happening.
No inquiry into COVID-19: does that mean a second wave of mistakes?
According to ITV news, Middlesbrough Council has just written to care homes stating that :
"It is likely in the coming days and weeks that we will see residents leaving hospital that are Covid-19 positive. If any homes are not able to accept residents with a positive result and isolate appropriately, will you please let [us] know...by 12 noon 18/09/2020".
No doubt other councils are doing the same, prompted by alarm over the upswing in numbers of positive tests over recent weeks. Given the disastrous way patients with COVID-19 were discharged into homes during the first wave of the virus, many staff are feeling understandably anxious. One care manager who received the email asked:
"Are they looking to spread the virus into homes again?".
Although a Department of Health spokesperson told ITV:
"No care home will be forced to admit an existing or new resident to the care home if they do not feel they can provide the appropriate care",
another care home manager told ITV News:
"Reading between the lines, the email is saying if you don't play ball and accept these patients you will be out in the cold.”
Can a repeat of earlier disaster be avoided?
David Rowland from the Centre for Health and the Public Interest argues that the root cause of excess infections in care homes is 30 years of market driven policies. Research from NHS Lothian showed that risk of infection increased in proportion to the size of the care home. In homes with 20 or less residents, risk of an outbreak was 5%, whereas for homes with 60-80 residents, risk increased as high as 83-100%. Staff terms and conditions are also crucial, with lower risk in homes paying sick pay and higher risk in those with lower staffing levels, employing agency staff and with workers who work across multiple sites.
The average size for a care home in the UK is 40 residents, with a CQC report finding that the larger the home, the lower its rating was likely to be. The reality is that larger care homes provide a better financial return for investors. Since from the 1990s governments have relied on private equity, hedge funds and Real Estate Investment Funds rather than public money to invest in care infrastructure, large homes have dominated. Currently 83% of care home beds are owned by for-profit companies. High occupancy rates, a requirement to ensure sufficient returns, have also been associated with increased risk of infection. Some homes simply had to admit patients known to have COVID-19 to maintain business viability.
Preparing for winter
In mid-July, an Academy of Medical Sciences report urged the government to use the remainder of the summer to prepare for a second wave of coronavirus during the winter. We are now seeing the beginning of the second wave, earlier than expected, with national lockdown imminent unless urgent action is taken. Commissioned by the government’s chief scientific adviser, Sir Patrick Vallance, the report warned that a resurgence of the virus had the potential to kill up to 120,000 hospital patients in a worst-case scenario. In theory, among other preventative measures, regular testing for care homes in England, under which staff would be tested weekly and residents every 28 days, has been available since July – but Care England says this has not been delivered. The COVID-19 pandemic has directed a spotlight on how little is known about this sector, and the lack of easily accessible, aggregated data on the UK care home population. A “dashboard” to monitor care home infections has been promised.
What must be done?
Rising infection rates and increasing hospital admissions will inevitably mean pressure once again on care homes to admit patients carrying the virus from hospitals. Care homes should not be forced to take transfers unless they are appropriately staffed and equipped and have necessary isolation facilities. Patients must be tested prior to discharge from hospital, and there is a pressing need for ready availability of testing for staff. There are around 120,000 staff vacancies in social care and testing can reduce further staff absence through supporting more rational decisions about need for self isolation. Vulnerable BAME staff (making up 48% of health and care staff in London for example) require additional protection.
Other requirements include a robust system for internet consultations with GPs, availability of bereavement counselling for staff as well as training in palliative care, and rapid access by care homes to necessary drugs. There should be no blanket use of ‘Do Not Attempt Cardio-Pulmonary Resuscitation’ orders and care home residents who become ill should not be excluded from hospital admission where they would likely benefit. Action is needed to eliminate as far as possible spread of infection within care homes, or spread by staff into the community. This must include maintaining adequate supplies of Personal Protective Equipment. The optimum use of Nightingale hospitals and private healthcare settings for ‘step-down’ COVID-19 care or isolation as an alternative to care home admission also requires serious consideration. Listening to the views of patients and relatives and taking these into account when decisions are being made is also crucial.
Prevention of community spread
In the wider community we still need effective policies to maximise population engagement in essential control measures. These include: physical distancing (re-instating the 2 metre distance rule); working and studying from home when possible; closing indoor service in pubs and restaurants; effective ventilation of homes and workplaces; a test, trace and isolate programme based on trusted local NHS, primary care and public health structures; locally based contact tracing and financial support available to make it feasible for those asked to self isolate to do so; a clear strategy for symptomatic and asymptomatic testing.
The future for care homes
In the long term, a change in the care home business model is needed with smaller sized homes and a new deal for staff with improved pay and training. KONP is also calling for a National Care and Support Service that will have overall responsibility for publicly provided residential homes and service providers and, where appropriate, for the supervision of not-for-profit organisations and user-led cooperatives. All provision will deliver to national standards. There will be no place for profiteering and the market in social care will be brought to an end.