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Posted by Chris Phillipson, Manchester Institute for Interdisciplinary Research on Ageing (MICRA)

Can society be trusted to run care homes? An age-old question but one which has come back with a vengeance with the emerging catastrophe caused by Covid-19. Of course, the signs have been there for some time, that disasters – such as those linked with climate change and pandemics – create havoc for institutions built to protect older people. In Europe, the impact of the 2003 heatwave is well-known – causing 35,000 excess deaths. France was especially affected with around 15,000 deaths – 1 in 5 occurring in residential and nursing homes. Despite claims that lessons were learnt from that disaster, the Covid-19 crisis is confirming once again the vulnerability of people living in residential and nursing home care.

Across Europe, thousands of people are dying in care homes: in Madrid, Spain, out of 3,000 deaths reported in nursing homes, in the month of March, 2,000 are thought to be Covid-19 related. In one area, Spanish soldiers reported finding elderly patients abandoned in care homes – in some cases dead in their beds. In Northern Italy, in one of the worst affected areas, hundreds of people in residential homes are reported to have died. In France, in the period up to April 3rd, a total of 1,416 covid-19 related deaths were reported among care home residents.

But here’s the thing: these are rough estimates. In countries such as France, Spain and the UK, reported Covid-19 deaths are for people in hospital – not care homes. Countries are now bringing estimates for the two sectors together but the delay is significant and when a full assessment of the impact of the virus is made, the scale of the tragedy affecting care homes may never be known.

What is likely to be the Covid-19 related mortality rate for care homes? One UK former regional director of Public Health has claimed that the UK Government is predicting a figure of 30%. Already, multiple deaths are being reported: at the beginning of April, 13 people (out of 90 residents) died in the space of a week in a Glasgow nursing home from what is suspected to be Covid-19.

Yet these deaths – although reported by the mass media – take second or even third place behind the undoubted tragedy affecting hospitals across Europe. And there is a tragedy unfolding for staff as well – invariably women on poverty-level wages – who across Europe report a lack of protection against the virus and shortages of equipment, let alone training in using any which is available. Union leaders in the UK have warned that staff are being threatened with disciplinary action for raising concerns about unsafe working conditions.

Covid-19 is leading to a crisis across all sectors of health and social care – but none more so than for residential and nursing homes. People go to homes – it is claimed – for their safety and protection. But the crises brought by climate change and pandemics are bringing huge dangers. Of course, these are largely of our own making: homes are too big; inadequately staffed; and financially insecure. Care homes float on an unstable mix of compassion, ignorance and exploitation, financed (increasingly) by private equity firms; staffed by the precariat.

But what is to be done? Any UK gerontologist has Peter Townsend’s The Last Refuge seared into their memory; a return to large public sector homes is unlikely to be a solution. And the privatization of care has thrown up numerous problems, not least: lack of rights for residents; poor quality of care; high costs; and financial mismanagement (see, further, Armstrong and Armstrong, 2020).

So where to go? Do we just accept the inevitability of high death rates of 30% or more in future crises? Increases in mortality are, though, only one part of the problem. The manner of dying is another: cut off from family and friends (who are – in the UK at least – now banned from visiting homes); surrounded by staff terrified of catching the virus themselves and passing it on to their families – risking their lives in the act of care.

For sure, the current residential and nursing home care model is broken. Herding vulnerable people into 100/200 bed homes has and is proving a disaster (again, The Last Refuge might have predicted that one). The question now is how people can best be protected from the succession of crises of the type currently faced.

Some immediate steps must be taken: first, greater transparency is needed about the Covid-19 related deaths which are occurring in residential and nursing homes: these need to be reported at least once a week in one of the UK Government’s daily briefings. Any clusters of deaths should be noted, whether in an individual home, or chain of homes, with the reasons for this explained. Second, the Government should underwrite an immediate tripling in the average hourly pay rate of care workers; it currently stands below the basic rate paid in most UK supermarkets. Third, a task force should be established to work as quickly as possible, to ensure that staff are given protection as well as appropriate training for working in care environments.

In the medium term, bold thinking is needed by the research community about the future of residential and nursing home care: challenging rather than colluding with current models of care. Privatization has proved a flawed model; but the public or not-for-profit sector does not provide a straightforward solution either. The way forward must certainly be to ‘downsize’ from ‘industrial scale’ care, looking at placing the running and financing of homes (with 20 residents maximum) into the hands of residents, staff and family members: co-operative care in all but name. Tightly regulated foster care, as a complementary strategy, may be another option. Crucially, such homes should develop strong (preferably intergenerational) links with groups in the surrounding community. Developing viable models along these lines will be challenging: but the task is urgent and must begin now. Can society be trusted to run care homes? Certainly not at present; re-thinking what might be developed for the future is now an urgent task.