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.
- Davies, W. (2020) ‘Flags, face masks and flypasts’, The Guardian Review, Issue No.122