Covid-19: Statement from the President and Members of the National Executive Committee of the British Society of Gerontology

Featured

Tags

, , , , , , , , , , , , , , , , , , , , , , ,

A pdf of this statement can be downloaded from the British Society of Gerontology website

The British Society of Gerontology is the learned society representing gerontologists in the United Kingdom. This is a statement from the President and Members of the National Executive Committee made on 20 March 2020 in relation to the unfolding political, policy and media rhetoric and government policy concerning age divisions in response to the COVID-19 pandemic.

We urge the Government to reject the formulation and implementation of policy based on the simple application of chronological age. We also call on government and media organisations to be cautious in their use of language. It is essential that we continue to foster generational and societal cohesion during the course of the pandemic. Only by bringing the generations together in this time of crisis can we ensure that the least damage is done to people living in the UK and other countries.

We affirm the prime goal to control and limit as far as possible the spread of COVID-19. To achieve this goal requires a clear focus on evidence-based practice, using high quality research. We fully support action taken to limit physical interactions, maintain hygiene standards and restrict non-essential travel, and we understand that actions to contain and delay infection will require disruption to our everyday lives.

We urge the Government to ensure rapid COVID-19 testing for our front-line health and social care workforce and the wide range of individuals and organisations who are leading the response to the pandemic. We are also in favour of providing tests for the wider population. This allows people to respond appropriately to the pandemic, ensuring that the right people isolate themselves at the right time. Wider testing is also essential to provide access to robust data that can be used for research and modelling to assist us now in responding to and containing the virus, and in preparing better for future pandemics.

However, for the reasons set out below, we object to any policy which differentiates the population by application of an arbitrary chronological age in restricting people’s rights and freedoms. While people at all ages can be vulnerable to COVID-19, and all can spread the disease, not all people over the age of 70 are vulnerable, nor all those under 70 resilient. Older adults are actively involved in multiple roles, including in paid and unpaid work, civic and voluntary activity in local communities, and providing vital care for parents, partners, adult children and grandchildren. Quarantining the more than 8.5 million people over 70 years of age will deprive society of many people who are productive and active and who can be a key part of the solution by supporting the economy, families and communities. If blanket measures are taken to quarantine older people when others in the population are not quarantined, this places additional burdens on families, communities and businesses, and causes harm to those individuals.

  1. As a population group, it is wrong and overly simplistic to regard people who are aged 70 and above as being vulnerable, a burden, or presenting risks to other people. Many people in this age group are fit, well, and playing an active role in society. Older people participate in paid work, run businesses, volunteer, are active in civil society and the cultural life of communities, and take care of family members including parents, spouses/partners, adult children (especially those living with disabilities), and grandchildren. There are currently more than 360,000 people over 70 in paid work, including one in seven men between 70 and 75 and one in sixteen women (see Table 1). Almost one million people over the age of 70 provide unpaid care, including one in seven women in their 70s. One in five people aged between 70 and 85, over 1.5 million people, volunteer in their communities. People in good health are especially likely to volunteer at older ages with almost a third of those in their early 70s doing so. Older adults should not be excluded but should be seen as a vital and necessary part of economic and community life.

2. Serious health risks particularly identified for coronavirus are prevalent across the population. Not only do high risks exist across age groups, but also many people in older age groups have no underlying health conditions. As indicated in Table 2, almost half of people in their early 60s have one of a range of health conditions (hypertension, heart disease, diabetes, lung disease, asthma or cancer). Almost one in five people in their 60s have two or more of these conditions.  More than 30% of people in their 70s have none.

  1. It may be correct that age itself on average is presenting a risk for coronavirus even without other health conditions. However, this will not be the case for all individuals, amongst whom biological age and immune responses vary greatly. More importantly, this will on average be a gradually increasing risk with any specific age being an arbitrary point on this line. Choosing an arbitrary age, such as 70, presents the age risk as binary. This poses dangers for people below as well as above the age threshold. People below the age threshold will not be charged with the same level of responsibility for preventing the spread of COVID-19 and may falsely believe that they are not at high risk of serious illness or death. Government messaging that people aged 70 and over are vulnerable due to their age runs the risk that other groups may not take seriously messages about the need to maintain physical distance from others and to self-isolate. Messaging about how to avoid catching and spreading coronavirus should apply to everyone irrespective of age.
  1. If people are to be motivated to change their behaviour, they need to accept that they are personally at risk (perhaps due to an underlying health condition or family circumstances). Sweeping age-related discrimination is unlikely to achieve the desired behaviour change. People who feel fit, strong and healthy will feel that the message does not apply to them and will characterise themselves as belonging to a group apart. The age-based messaging also risks pitting young against old. It may make older people feel resistant to what they are being told, which they do not see as applying to their situation. Media, government and public health professionals should strive to use language that resonates, rather than obfuscates, how people identify in their everyday lives.
  1. People of all ages, when staying at home or trying to distance themselves physically from others, remain members of families, friendship networks and communities. All measures should be implemented with an awareness of people’s need for social support and solidarity. It is clear that physical distancing needs to happen across the whole population at once, and sensible rules for maintaining mental and physical health during this period need to be employed. We cannot implement a policy that will severely weaken the physical and mental health of some age groups through isolation while others are more protected. Given the centrality of both mental and physical well-being, there is a need for clear guidance on what people can do to maintain and improve their physical and mental health while keeping physically apart from others. This will only be effective if the message from Government is not divisive around age.
  1. Research points to the fundamental importance of social connections for personal well-being and physical and mental health. The COVID-19 crisis has prompted considerable discussion of loneliness and social isolation amongst older people suggesting, quite wrongly, that these are vulnerable states that apply to older people alone. Increasingly, media discourse is also promoting the view that all older people are lonely and socially isolated. Contrary to this discourse, the evidence shows that loneliness and social isolation affect people of all ages. Recent studies suggest that young adults may be at greater risk of loneliness than older adults, with one in ten people aged 16-24 years being often lonely, compared to three per cent of people aged 65 and over (see Table 3). We also know that people can be lonely or socially isolated even when living with others. Loneliness and social isolation are already intractable social issues that warrant thought and action about connectedness and support across all age groups and communities. Evidence shows that being seen to be part of community life can act as a buffer against feelings of isolation, give people a sense of meaning in life, and protect against depression. Voluntary and community organisations, charities and statutory organisations should receive financial and structural support during this time to continue their longstanding work on tackling isolation and loneliness regardless of age. They should also be supported and encouraged to develop new strategies to improve the number and quality of people’s social connections during the current time. This should include using both old and new communication technologies, ranging from radio and TV to the internet and digital devices, to facilitate social connections between people of all ages. We should be thinking of this period as an opportunity to bring people and generations together, especially by helping to bridge digital divides across society where these exist.
  1. Living alone is a separate issue that has not been adequately considered or addressed. While this is an issue that disproportionately affects people aged 75 and over, especially older women, it affects all age groups and generations. About a third of men aged 80 and over are single, divorced or widowed, but this is the case for 70 per cent of women in this age group (see Table 4). There is an implicit assumption in much discussion about COVID-19 that people will have co-resident family members to look after them, to recognise that they are ill, to keep them hydrated, to help them if they are unable to get back to bed after going to the toilet, to try to encourage some nutrition or to call an ambulance. Co-resident family members can also advocate for hospitalisation or hospital care if needed. If people live alone and no-one is permitted to see them, who will do this? With a simple message to older people who live alone that they must cut themselves off from others, we are also conveying the message that we expect them to become ill without care and even die. Some countries have constructed and converted isolation centres to enable people with coronavirus to move to a place where they can be cared for appropriately, thus isolating them from families and friends but also offering access to care. There is an urgent need for clear policies aimed at supporting people who live alone of all ages. Equally, we need policies that can provide testing, intermediate care facilities (potentially requisitioning hotels, student accommodation, or office buildings), and tangible support for people who live alone. 
  1. As well as health and social care workers, family and friends who will need to provide care to people who become unwell form the front line of society’s response to the pandemic and will need to be acknowledged and treated as such. For many people with families who they love and with whom they live or who live within close proximity, it is anathema to leave them to be severely ill, self-care in that state, and potentially die alone. Overwhelmingly, family members will provide hands-on care for one another. They will ignore entreaties to physically distance as they tend to their children, their spouses/partners and their parents and grandparents, knowingly taking risks as they do so. Families will do this for the loved ones they live with, and those they do not live with. To expect otherwise is to ignore the interconnectedness of families and the behaviour of people. Here, rather than tell families to ignore each other, we need to offer rapid testing, advice and supplies (masks where useful for intimate care, eye protection, gowns, gloves, sanitisers, soap). We should also be providing financial support for people faced with additional costs associated with managing daily life when family members have coronavirus, such as keeping the washing machine running and purchasing cleaning and hygiene products. We need to ask people to isolate as connected clusters rather than keeping loved ones apart. We need to work with human behaviour and not against it.
  1. Special thought should be given to how people might connect with loved ones who live in care settings. Denying people the chance to see their friends and relatives where the physical and mental wellbeing of both depends on that contact, and where other forms of contact may well not be facilitated, is a most drastic curtailment of human rights and needs. Testing becomes crucial, to know who has had the virus, who may be immune, and who may be able to visit in a safe way without danger. Policy and practice should seek innovative ways for people to visit their loved ones virtually, or across physical or spatial barriers. We need to have a much more nuanced and evolving discussion of this particular challenge.
  1. Some common sense is also needed about so-called “self-isolation”. Socially isolating in a large house with a garden, good internet connection and a steady income is a completely different experience to socially isolating in a tiny flat, with no internet and under financial stress. Online food and other deliveries, which feature as a key policy response to coronavirus, are not an option for a large number of people, do not apply at all in many rural areas, and are already difficult to obtain as companies struggle to meet surging demand. We need to find a way to allow people to walk or cycle to local shops, to take exercise (for themselves and their pets), and to wave at one another and make social connections while maintaining a safe distance and observing hygiene requirements, without being singled out or intimidated. We need to think about sustainable policies, perhaps staggering who can go out for what purpose and when, how many people can be at particular places at a particular point in time, and national and reliable delivery of hand sanitisers to food shops and pharmacies on entry and exit. Maintaining physical and, especially, mental health whilst keeping people safe and well is a priority. Exercise, personal mobility and human contact are key to healthy ageing and need to be promoted long beyond the current pandemic.
  1. A key message from research on social aspects of ageing is that policy and practice should be attuned to the diversity of older people in countries like the UK. The older population is far from homogenous and differs substantially according to such characteristics as age, gender, ethnicity/race, sexual orientation, disability, socioeconomic status, marital status, household composition, place of residence and care roles. Given the diversity of older people, and the considerable social and spatial inequalities that characterise later life, broad-brush policy approaches based solely on chronological age are likely to disproportionately disadvantage some groups. They may also ignore the specific needs of marginalised groups of older people, including those who have particular health conditions, live in long-term care settings, are homeless, or are imprisoned. Research on ageing has made considerable progress in recent years in drawing attention to the heterogeneity of older people. It would be a highly retrograde step if this progress was undone by policy measures that reinforce the view that all people over a certain age share a particular set of characteristics.
  1. As well as preparing policies for living through this pandemic, we need to think about death, and the potential for death rates not witnessed for generations in the UK.  We need sensible, realistic and emotionally supportive frameworks for attending funerals, and for coping with individual and collective grief. Such frameworks are needed regardless of the age of people coming to terms with loss.

In this unprecedented period, we call for urgent and ongoing data collection and rigorous analysis of social and economic inequalities, and of the impact of inequalities through this crisis on the living conditions of people, their mental and physical health, and mortality. We call for urgent policy action to redress these inequalities. COVID-19 is bringing into stark vision the impact of many years of politically motivated austerity policies that have substantially eroded health and social care services and community and voluntary sector support. The crisis demands an urgent reversal of these policies and calls for future investment in social as well as health care. In particular, we call for the social and domiciliary care workforce to be fairly treated. We call for them to be protected as front-line workers against this epidemic. We call for their high levels of skill to be recognised not only in the form of words, but also in terms of their pay, job security and working conditions.

If physical distancing policies are to succeed, they need to take account of who people are, how they perceive themselves, how they behave, and their emotional needs. Such policies will be difficult to police, and enforceable sanctions are hard to imagine. We need to carry the hearts and minds of the nation with us in the months ahead if we are to ensure the least physical interaction and least spread of the disease. The COVID-19 response emphasises more strongly than ever before the need for co-ordinated ageing policy that cuts across government departments.

We note that policies identifying an arbitrary chronological age for restrictions of human liberties are out of line with approaches in other jurisdictions, including Scotland and Ireland.  People of all ages are privileged with the same rights and policies need to be applied at population level. Ageism – the stereotyping, prejudice, and discrimination against people on the basis of their age – has detrimental consequences for societies and individuals. We reject firmly the ageist and stereotypical assumptions that underlie public and policy pronouncements that rely solely on the application of chronological age.

We close by declaring our strong support and admiration for clinicians making hard decisions, including, in due course, potentially about rationing life-saving resources. In anticipation of these, we stress that it is not possible for clinicians to make moral judgments about the value of human life based on age. Faced by the pressures of a pandemic, clinicians will in all likelihood know next to nothing about the lives of the people they are being asked to treat and cannot weigh one life against another. All clinical decisions for access to testing and treatment as they unfold should be made on clinical need; using age alone as a criterion for decision making is fundamentally wrong.

Signed, 20 March 2020

Professor Thomas Scharf
President of the British Society of Gerontology
Newcastle University

And Members of the National Executive Committee of the British Society of Gerontology:
Professor Carol Holland, Professor in Ageing, Lancaster University
Professor Andrew Newman, Professor of Cultural Gerontology, University of Newcastle
Professor Debora Price, Professor of Social Gerontology, University of Manchester
Dr Tine Buffel, University of Manchester
Dr Gemma Carney, Queen’s University Belfast
Dr Gary Christopher, University of the West of England
Dr Paula Devine, Queen’s University Belfast
Dr Martin Hyde, Swansea University
Dr Matthew Lariviere, University of Sheffield
Dr Hannah Marston, Open University
Dr Wendy Martin, Brunel University
Dr Charles Musselwhite, Swansea University
Dr Tushna Vandravela, Kingston University

And endorsed by the following Members of the British Society of Gerontology as at 16th April 2020:

Sheila Mackintosh, University of the West of England
Dr. Joanna Cross, Freelance Consultant, Bristol
Dr Bram Vanhoutte, Derby Research Fellow, University of Liverpool
Emeritus Professor Bob Woods, Bangor University
Professor Holly Nelson-Becker, Social Work Division Lead, Brunel University London
Robin Webster, Irish Centre for Social Gerontology , NUIGalway
Dr Carol Maddock, Swansea University
Professor Andrew King, University of Surrey
Dr John Woolham, King’s College London
Dr Sue Westwood, University of York
Ruth Winden, Director, Older Yet Bolder
Bridget Penhale, University of East Anglia, Norwich
Dr Melanie Chalder, University of Bristol
Dr Katharine Orellana, King’s College London
Dr Bethany Simmonds, Senior Lecturer in Sociology, The University of Portsmouth
Dr Chad Witcher, Senior Lecturer, School of Sport, Health and Exercise Science,                      University of Portsmouth
Dr Deborah Morgan, Senior Research Officer, Swansea University
Dr Robin A Hadley, Associate Lecturer, Manchester Metropolitan University
Prof Rose Gilroy, Newcastle University
Dr Anna Wanka, Goethe University Frankfurt am Main
Dr Lorna Warren, Senior Lecturer, University of Sheffield
Professor Julia Twigg, Emeritus Professor of Social Policy and Sociology, University of             Kent, Canterbury
Dr Jenny Inker, Assistant Professor, Virginia Commonwealth University
Dr Bernadette Bartlam, Honorary Senior Research Fellow, Keele University
Dr Suzanne Moffatt, Reader in Social Gerontology, Newcastle University
Professor Malcolm Johnson, University of Bath
Dr Michele Board Principal Academic Nursing Older People, Bournemouth University
Dr Lucy Smout Szablewska, Durham University/independent researcher
Prof Karen West, University of Bristol
Dr Bruce Davenport, Research Associate, Newcastle University
Dr Malcolm J Fisk, De Montfort University
Deborah Gale, Intergen Design Leader, Encore Fellows UK & The Age of No Retirement
Dr. Hans-Joachim von Kondratowitz, Senior Advisor German Centre of Gerontology,                Berlin
Professor Vanessa Burholt, Professor of Gerontology, Centre for Innovative Ageing,                  Swansea University and Faculty of Medical and Health Sciences, University of                      Auckland
Emeritus Professor Peter G. Coleman, University of Southampton
Professor Judith Phillips, Professor Judith Phillips, Professor of Gerontology, University            of Stirling and UKRI Research Director, Healthy Ageing Challenge
Dr. Snorri Bjorn Rafnsson, Associate Professor of Ageing and Dementia, Institute for
        Ageing and Memory (IAM), School of Biomedical Sciences, University of
        West London
Dr Ann Leahy, Irish Research Council, Post-Doctoral Fellow, Maynooth University
Dr Marianne Markowski, Member of the Centre for Chronic Illness and Ageing,                             University of Greenwich

Lost in the Community: A Brief History of Covid-19 and Residential and Nursing Home Care

Tags

, , , , , , ,

Chris Phillipson, Manchester Institute for Collaborative Research on Ageing (MICRA)

So, the question (see blog on April 8th) ‘Can society be trusted to run care homes?’, seems to have been answered: ONS data indicate that over the period from March 2nd to May 1st, 12,526 deaths in residential and nursing homes involved Covid-191. Figures produced by researchers at the LSE put the numbers of deaths, caused directly or indirectly by the pandemic, at around 22,0002. Of course, given the ‘widespread failure to record Covid-19 on the death certificates of residents’3, any figure will almost certainly be an under-estimate. The answer to the question, then, seems clear: society cannot be trusted to ensure the safety of those living in residential and nursing home care. Care homes seem to have been abandoned or ‘lost in the community’ for a significant part of the pandemic, with question marks raised over the role of a number of responsible bodies.

A starting point must be the Scientific Advisory Group for Emergencies (SAGE) which began meeting towards the end of January to discuss the implications of the virus. A key issue with SAGE concerns its composition. Older people, and those in residential care in particular, were always likely to be amongst the group most affected by Covid-19. Unfortunately, SAGE lacked specialists either within gerontology or geriatric medicine, or, crucially, that of social care. As Anthony Costello commented: ‘The makeup of SAGE reflects an oddly skewed and overwhelmingly medical view of science’4. Lack of expertise in social care was a particular disadvantage given the initial strategy of mitigation through ‘herd immunity’. The dangers attached to this approach could only be avoided if  at risk groups were effectively ‘shielded’ from the virus. However, the reality during this period was a chronic shortage of protective equipment, the absence of testing for staff and residents, and lack of controls over visitors (including agency staff) entering homes. 

The limited steps taken to ‘cocoon’ care homes seemed to reflect the official line from Public Health England (up to March 13) that ‘it remains very unlikely that people receiving care in a care home or the community will become infected’5. This view – which ignored evidence from as early as February of the impact of the virus in Italian nursing homes – was important because it provided cover for NHS managers to transfer Covid-19 patients back into the community to free up hospital beds. Indeed, a ‘divide and rule’ approach appears to have been adopted in health care policy, with protecting the NHS viewed as the main priority. William Davies views this as linked to the way in which the health service has become ‘entangled with a host of British icons’6, an institution to be protected at all costs. Stopping the NHS from being ‘overwhelmed’ became a crucial element in policy during February and March. In reality, this meant abandoning any pretence of ‘shielding’ care homes. According to a Reuters investigation, during mid-March, an estimated 15,000 patients were transferred out of hospitals and back into the community. Reuters cite the following from an NHS plan issued on March 17th: ‘Timely discharge is important for individuals so that they can recuperate in an appropriate setting for rehabilitation and recovery’7. In fact, for those patients discharged with Covid-19, settings were rarely appropriate nor likely to enable recovery. A survey conducted in late April/early May by the Alzheimer’s Society of 105 care homes found: 33% had taken in Covid-19 residents who had been discharged from hospital;  58% were unable to isolate people suspected of having Covid-19; and 43% were still not confident in getting a supply of PPE8. Several managers complained that they felt pressured to accept infected patients either directly by the NHS or council officials or through an underlying sense that it was their duty to society. In the NHS plan, cited by Reuters, care homes were: ‘exhorted to assist with national priorities’. But the human traffic was all one way. One care homeowner, quoted in the Sunday Times (17/5/2020), reports being sent a public health document on March 13thwhich said that: ‘if any of our residents get significantly ill, they wouldn’t be allowed into hospital and would have to die in their [care] home’. 

Given the pace of change during March, there was an urgent need for a responsible body to monitor pressures affecting the care home sector. The Care Quality Commission (CQC) would normally be the organisation playing such a role, given that it is charged with ensuring: ‘health and social care services provide people with safe, effective, compassionate [and] high quality care’. Yet, precisely at the point when people were being ejected from hospital, the CQC suspended (on March 16)  routine inspections in care homes following pressure from ‘system leaders and NHS bosses’9. The NHS Confederation was quoted as saying that ‘Front line staff will breath a sigh of relief’9, and that inspections would be an ‘inevitable distraction’9. The RGCP said it would enable GPs to dedicate their time to providing care. This action was taken ahead of the implementation of an alternative inspection methodology to assess how homes were managing the spread of the virus. Given doubts about the quality of care in the sector, dropping inspections was always likely to be risky. The CQC’s 2019 State of Care10 report found only 3% of homes rated as ‘outstanding’; 15% (3,373 homes) were rated as ‘needing improvement’; and 1% (285) inadequate. Evidence about the monitoring of homes since the dropping of inspections is not reassuring. The survey by the Alzheimer’s Society cited earlier found that 75% of care homes reporting that GPs were reluctant to undertake visits. The CQC itself delayed for nearly a month before it started asked care homes specifically whether people were dying from confirmed or suspected Covid-1911. By mid-May, families of care home residents were calling for the restart of CQC inspections, with the director of the Relatives and Residents Association quoted as saying: ‘As care homes went into lockdown and restricted visits from family members, this coincided with a relaxing of the normal checks and processes to ensure older people receive quality care…Inspections should be restarted with training, PPE and selecting the homes where concerns have been raised or which are known to be struggling’12.

And what of the other responsible body: that of care home providers? With 15,000 care homes in England alone, developing a unified response to the Covid-19 crisis was always going to be a challenge. Certainly, owners have reason to complain about their treatment both by the Department of Health and Social Care, and the NHS. But they must also take their share of the blame. The care sector went into the crisis badly prepared, with (in England) a 40% staff turnover; 122,000 vacancies; 25% of workers on zero hour contracts13; and financial instability a major problem for large and small homes alike. Complaints have been voiced about the cost of PPE, but the lack of any central planning means that homes compete with one another for supplies, driving up costs. Even more serious has been the reliance upon (increasingly expensive) agency staff (10% of the social care workforce). The tendency for agency workers to be employed across multiple homes, may itself, according to a report from PHE, have been a factor in the spread of the virus14. Finally, the big five providers of residential and nursing home care – averaging over 10,000 beds – might have been expected to do some long-term planning for Covid-19 type situations. However, their own financial difficulties restrict what they can do. Weiss observes that the 26 largest providers of care home services in the UK pocket around £1.5bn from an annual revenue of £15bn for lease agreements, dividends, and debt repayments: ‘these businesses need profit margins of at least 12 per cent to be able to repay their debt, before reinvesting in staffing and the running of their homes, which could be unrealistic in a sector that operates on thin profit margins’15. And profit margins are likely to become even slimmer as deaths from Covid-19 increase costs and reduce bed occupancy. 

What steps need to be taken to move forward from the present crisis? The following suggestions are made to start a debate:

First, and as an immediate change, SAGE needs re-balancing: a social care specialist needs to be brought onto the committee (along with other social scientists), to provide authoritative advice on issues facing the care home sector.

Second, an enquiry into the handling of Covid-19 is inevitable but this needs to be actioned sooner rather than later and organisations such as BSG, BGS, Age UK and CfAB should lead any investigation.

Third, Covid-19 has demonstrated (again) the dysfunctional relationship between the NHS and Social Care, to such an extent that the likelihood of integration has been put back for a considerable period of time. Social care in particular needs to work out a unified voice and vision which can allow it to work on an equal basis with NHS partners.

Fourth, ultimately, the care crisis and Covid-19 is a crisis about the care of people with dementia (70% of those in residential homes have dementia or severe memory problems). The system has been found wanting, in part because the care of people with dementia is itself in crisis, with new ideas desperately needed about finding the best environment for those unable to live in their own homes. Indeed, the pandemic is a reminder that we need to balance research about ‘cures’ for dementia, with more about the type of care which can both protect and empower people at the most vulnerable point of their lives.

Sources

  1. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/latest#main-points
  2. http://www.lse.ac.uk/News/Latest-news-from-LSE/2020/e-May-20/Care-home-residents-account-for-over-half-of-excess-deaths-during-COVID-19-pandemic.
  3. https://www.newstatesman.com/science-tech/coronavirus/2020/04/coronavirus-care-homes-carers-elderly-deaths-PPE
  4. https://www.theguardian.com/commentisfree/2020/apr/27/gaps-sage-scientific-body-scientists-medical
  5. https://www.gov.uk/government/publications/guidance-for-social-or-community-care-and-residential-settings-on-covid-19/guidance-for-social-or-community-care-and-residential-settings-on-covid-19#guidance-on-facemasks
  6. Davies, W. (2020) ‘Flags, face masks and flypasts’, The Guardian Review, Issue No.122
  7. https://www.reuters.com/investigates/special-report/health-coronavirus-britain-elderly/
  8. https://www.alzheimers.org.uk/news/2020-05-13/care-homes-left-fend-themselves-against-coronavirus
  9. https://www.hsj.co.uk/primary-care/cqc-suspends-routine-inspections-amid-covid-19-outbreak/7027132.article
  10. https://healthcare.radarsoftware.co.uk/media/1284/20191015_stateofcare1819_fullreport.pdf
  11. https://www.theguardian.com/society/2020/apr/15/uk-care-home-inspectors-did-not-ask-about-covid-19-deaths-until-april
  12. https://www.theguardian.com/society/2020/may/14/care-home-residents-families-demand-restart-of-inspections
  13. https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx
  14. https://www.newstatesman.com/2020/05/agency-staff-spread-coronavirus-between-care-homes-early-pandemic-unpublished-phe-study
  15. http://www.wired.co.uk/article/care-homes-coronavirus