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4th Edition, June 2nd, 2020 Dr Alisoun Milne

Notes on a Scandal: Coronavirus & Care Homes for Older People

Covid-19 has exposed serious inadequacies in the UK’s social care system (Pollock et al, 2020). It has made visible, and amplified, a pre-existing seam of governmental ignorance and indifference of catastrophic proportions. Very limited national attention is paid to social care, it is poorly resourced, fragmented and infrastructurally weak, and is conceptualised as the handmaiden to health care. As older people are the majority users of both community based and residential social care services, Covid-19 has, by default, also made visible political, structural and societal ageism and public and policy ambivalence towards older peoplewho need support from services and to the staff that work in them. 

The most stark evidence of dereliction of duty relates to care homes. About 410,000 older people live in care homes in the UK, half of whom are publicly funded. The majority are aged 85 years or over, have complex co-morbid conditions and need help with activities of daily living. Dementia is estimated to affect four fifths of residents (Dening and Milne, 2020). There are 15,487,000 care homes in the UK; over 90% are independent providers and the majority are for-profit (LaingBuisson, 2018). 

Covdi-19 related deaths in care homes is both a tragedy and a scandal. The death rate in care homes attributable to ‘all causes’, has increased by 220% since the start of the outbreak. Official figures – from May 16th – estimate that 12,526 residents have died from coronavirus. Another 10,610 ‘excess’ deaths from ‘other causes’ linked to the virus have also been recorded; these relate to deaths arising from GPs being unable to visit the home and/or care homes being discouraged, or sometimes unable, to send residents to hospital for treatment (O’Dowd, 2020). A third – as yet unverified – cause is residents dying as a consequence of ‘being left alone without adequate food, water’ or access to pain relief. Thus, overall, 22,000 deaths in care homes have been the result, either directly or indirectly, of Covid-19. This number represents over half of the (predicted) total of all Covid-19 deaths in the UK. It is a figure that warrants analysis as it raises serious questions about what the hell happened to care homes!  

There are a number of dimensions to this story of abandonment, mismanagement, and deceit. From the beginning of the crisis the government was preoccupied with protecting the NHS and ramping up NHS capacity. This focus was at the expense of protecting ‘at risk populations’ including care home residents. Valuable early opportunities to reduce the chance of the virus entering care homes were not taken. As Dr Harwood, a Consultant Geriatrician, points out, ‘Care homes were always vulnerable, residents are frail and live communally…’. The situation was made worse by a process of mandating early discharge to care homes of older people who no longer needed inpatient hospital treatment. These patients were not routinely tested. Those who had the virus brought it into care homes where it quickly spread creating, what the scientists call, ‘fatal cluster effects’. It was not until the 15th April, after 5,700 patients had died in care homes or hospitals[1], that the government ‘required’ all patients discharged from hospital into a care home to be tested (Iacobucci, 2020). 

The Department of Health and Social Care (DHSC) was also slow to advise against visits to care homes; another obvious route of infection transmission. Whilst Scottish Care – a representative body for social care in Scotland – advised care homes to close to visits on 11th March and Nursing Homes Ireland – which represents hundreds of Irish homes – banned non-essential visits six days after the first confirmed case in the country, the DHSC did not act until 2nd April.

The other key issue relates to lack of effective protection. Care homes were woefully unprepared to deal with the virus, in good part because they were not seen as a priority for receipt of PPE and testing. An ‘action plan for care homes’ was not published by the DHSC until April 15th:  6 weeks after the government’s national ‘coronavirus action plan’ (which made no mention of care homes) and 3.5 weeks after the Prime Minister announced the UK lockdown. On May 15th – a month after the care homes action plan – Age UK reported that ‘many homes are struggling to access PPE and testing’. Even where testing is available it may not be local: staff from a home in Derbyshire are obliged to travel for an hour to Grantham to get a test if they want one. 

As recently as May 18th, the Chairman of the Science and Technology Committee wrote a letter to the Prime Minister stating that the government’s ‘ability to make tests available to care homes has been inadequate’ throughout the pandemic. He accused Public Health England (PHE) of – effectively – abandoning care homes in the first critical weeks. Despite official reassurances from Matt Hancock about the ‘protective ring thrown around care homes’, on May 20th many homes reported that they were ‘still waiting for tests’ and ‘a supply chain to tackle PPE shortages is weeks away’ (Carter, 2020). 

There are a number of reasons for this failure. Which agency is responsible for overseeing and managing, the provision of PPE and testing to care homes is one important question.  There has been considerable confusion about this. PHE, the Care Quality Commission (CQC) and the DHSC have repeatedly passed the buck about who should manage tests, giving mixed and contradictory messages. Care homes report being told, in the same day, that it’s not CQC but PHE and then later on the opposite.   

A key barrier to understanding what was happening was lack of data. The National Care Forum[2] (an independent care sector body) describes care homes as planning their response ‘with their hands tied’ because data about outbreaks were not published until the end of April. PHE had counted more than 4,500 Covid-19 outbreaks in care homes before it issued its findings. For many weeks the government did not include deaths in care homes in its official statistics. This underscores its lack of understanding of the risks care homes were facing and as the death toll rose, its reluctance to acknowledge its own role in contributing to these.  

Funding issues are also a contributory factor. In mid May the Government released a £600m cash injection for care homes to help control infection. English Councils have also been given £3.2bn ‘crisis funding’ to support the adult social care sector through the pandemic. These sums have been dismissed as ‘derisory’ by care home managers who consider it insufficient to cover the costs of PPE let alone the extra costs related to testing and the provision of additional staffing. Extra staff were needed to provide cover for sick colleagues and to be able to offer 1:1 ‘isolation care’ to residents with the virus or those discharged from hospital. Some care homes have complained too that they have ‘struggled’ to gain access to the funds local authorities have been allocated.

This inertia and confusion speaks to a larger issue about the nature of the care home sector. Social care services in the UK are among the most privatised and fragmented in the Western world (Dening and Milne, 2020). Care homes operate in the market and are driven by commercial principles; these shape their priorities and whilst there are many examples of excellent care, the quality of care overall is uneven, variable and vulnerable to the vicissitudes of investors and the stock market. Although care homes are regulated by the CQC they sit outside the purview of the public sector; they occupy a liminal ‘off the radar’ status inside the care system, in communities and in the public consciousness. There is also an inherent conflict between care homes being a place of ‘care’ and a place of ‘home’ (Mikelyte and Milne,2016). 

Residents are not the only group placed at risk. At least 131 care staff[3] have died from coronavirus. The ONS estimates that (social) care staff are twice as likely to die as healthcare workers (and members of the general population). Most are women. Workers – who called a whistleblowing helpline operated by Compassion in Care – described the ‘horrendous’ unsafe conditions they are facing over lack of PPE and the terrible impact this is having on their mental health and wellbeing. In mid April care sector bodies wrote to Matt Hancock to alert him to the fact that that ‘this army of incredible, often low paid and undervalued care staff’ are risking their health and lives to deliver care to some of society’s most vulnerable people (Dyer, 2020). Staff absences have been running at 10% to 20%. In a sector already facing a recruitment and retention crisis, a moment of maximum peril is being confronted with a bare minimum of resource.

There is another embarrassing dimension to the care home story of shame. In 2017 a report – Exercise Cygnus – was commissioned by the government to explore the UK’s preparedness for the extreme demands of a flu-like pandemic. It concluded starkly that Britain ‘was not adequately prepared’. Three of the report’s key recommendations were to: boost the capacity of care homes, increase the number of care home staff and significantly increase supplies of PPE. It is clear that this was not implemented or even discussed with local authorities or care homes. If it had ‘the care home sector would have been in a much better place at the start of the pandemic’ (Martin Green, Chief Executive, Care England[4]).  The government also had evidence from other European countries – exposed to the pandemic before the UK – upon which to base a plan. Both Spain and Italy had experienced significant numbers of care home deaths: a pattern that we could have learned from.

Hubris also played a role. At no point has anyone representing the government acknowledged wrongdoing. This is not only an act of betrayal but one of mistruth. Talk of a ‘protective ring’ rings hollow in the ears of families who have lost relatives and to care home staff with no access to PPE. The politicians’ mantra lacks credibility and is replete with falsehoods and spin.

I will leave the last word to a man whose father died in a care home in April: 

It’s a kind of an indictment of the way the care system has been seen over this crisis and reflects how we see older people in care homes …they’re sort of expendable, not a priority and not deserving of treatment. Many deaths, including my dad’s, could have been prevented and that’s the thing I can’t forgive…it’s just wrong… so very wrong. 

Dr Alisoun Milne, Professor of Social Work and Social Gerontology, University of Kent

References  

Carter, R. (2020) Covid-19: The support UK care homes need to survive, British Medical Journal, 369: m1858.

Dening, T. and Milne, A. (2020) Mental Health in Care Homes for Older People, in T. Dening, A. Thomas, R. Stewart, J-P. Taylor. Oxford Textbook of Old Age Psychiatry, 3rd edition, Oxford: OUP .

Dyer, C. (2020) Covid-19: Doctors make bid for public inquiry into lack of PPE for frontline workers, British Medical Journal, 369: m1905

Iacobucci, G (2020) Covid-19: Care home deaths in England and Wales double in four weeks, British Medical Journal, 369: m1612 

LaingBuisson (2018) Care of Elderly People: Market Survey 2016-18, London: Laing and Buisson.

Mikelyte, R and Milne, A (2016) Exploring the Influence of Micro-cultures on the Mental Health and Well Being of Older People Living in Long Term Care, Special Issue of Quality in AgeingMental Health and Later Life, Vol 17(3), 198-214.

O’Dowd, A (2020) Covid-19: Care home deaths in England and Wales rise sharply British Medical Journal, 369: m1727.

Pollock AM, Clements L, Harding-Edgar L (2020) Covid-19: why we need a national health and social care service. British Medical Journal 369: m1465.

 


[1] In England and Wales 

[2] NCF is the membership organisation for not-for-profit organisations in the care and support sector

[3] These will not all be care home staff but the majority will be 

[4] Care England, a registered charity, is the leading representative body for independent care services in England