David Oliver: Care homes need our support in the covid-19 era and beyond

What do care homes have to do to get a break in England right now?

Before the first UK covid-19 deaths in March, care homes got precious little attention in mainstream news media, in serious policy solutions, or in NHS planning. Then through spring, and into summer, they coped with serious shortages of Personal Protective Equipment (PPE) and testing for staff or residents on a scale far worse than the NHS—where supply problems were bad enough.

Care homes faced a government policy, only halted in mid-April, of discharging hospital patients infected with covid-19, or untested back in to care homes they already lived in, or into new care home placements to help keep acute beds free—even though homes, leaders of their professional associations, and public health experts were shouting about the risks and their ill-preparedness to cope with this mass transfer of infection risk. 

We were seven weeks beyond the first UK death from covid-19 before a plan for adult social care covid-19 support was announced. This was long after equivalent plans for the NHS. It was as if the social care sector, including care homes, had been an afterthought. Remember, there are over 400,000 care homes (with or without nursing) in England in around 11,400 facilities. They are among our most dependent citizens and they outnumber people in hospital beds by over 3:1. Yet their needs seemed tangential to our pandemic response.  

Throughout March, April, and May there were hundreds of outbreaks each week reported from care homes, which have now slowed to tens—thank goodness.  

By the 6 of November, an estimated 15,659 people had died in care homes from covid-19 according to the Office for National Statistics (around a third of all deaths in England). And by 30 October an estimated 22,948 excess deaths (compared to five year averages for those months) had occurred in residents. 

Throughout the pandemic, the care home sector has complained of inconsistent, ever changing, and opaque guidance from central bodies, and ongoing overpromising and truth mangling over real life access to testing or PPE—despite big headline numbers and sound bites.

There were national bans on visitors and restrictions on visiting imposed in spring, though many care homes beat the government agencies to it out of concern for infection risks to their residents.

Homes with covid-19 outbreaks found themselves dealing with contingency they were never designed, staffed, or trained for. Trying to care for a large number of residents all confined to their own rooms with no access to public areas, without the protective equipment, infection control support, or training required, was bad enough. Trying to do it with staff themselves going off sick, or self-isolating, or with agency staff understandably scared to take shifts, and with managers working long hours, doubling up as carers, or staff living on site for days, made it tougher still. 

Evidence gathered along the way has also shown that outbreaks rely on staff unwittingly spreading infection when they don’t know that they are infectious—especially those working on multiple sites. Larger homes or those employing the most agency staff or less able to support paid sick leave are hit hardest with outbreaks.

There are some superb models around the country of clinical teams—whether GPs, geriatricians, nurse specialists and advanced care practitioners, and palliative care teams supporting care homes. They have done sterling work throughout the pandemic. But there have also been far too many stories of care homes struggling to get the support they needed from local NHS teams. for sick or dying residents who needed additional support within the home, or hospital admission where it was the best option. 

Fast forward to this autumn and on the surface things might look better. We have more testing capacity throughout the health and care system. There are now belatedly agreed policies around transfer of patients from hospital and mitigation of risk when they arrive. There is better, if imperfect, access to PPE and testing for staff. And there are a range of good practice guidelines. The government has appointed senior social care professionals to support national covid-19 policy, planning, and communications. The Care Quality Commission (CQC) has been asked to credential designated care homes to take infected patients in safely, until they are no longer a risk.  

The parliamentary Health Select Committee has heard extensive evidence about what went wrong for care homes over the past few months and is drawing up recommendations. There is promise in vaccines, which from what we know so far, do seem to work for older people—though the logistics of rolling them out to vulnerable groups are not negligible.

These events and key data around them are beautifully encapsulated in a new report from the International Long-Term Care Policy Network, “The Covid-19 Longterm Care Situation in England”.

I wish I could say the problems are over though. For starters, care homes are getting a relentless reputational battering in the media over visiting restrictions. I think we all realise by now why campaigning organisations like John’s Campaign, Age UK, Amnesty International, and the British Geriatrics Society see visiting restrictions as in infringement of human rights, as inherently age-discriminatory, and as having appalling consequences for the physical and emotional health of residents. Care home residents are generally in the last phase of their life, so their risks of dying from covid-19 bought in by a family member have to be balanced against their risks of death by other causes, so restricting visits from family seems unreasonably harsh.

Against that, they have to consider infection risks to all residents and keeping further outbreaks out of homes. They could face criminal or civil action over preventable outbreaks and deaths, and action by the regulator could lead to their closure.

Yet, they have to read deeply unfair headlines about “Jail breaks” and “Heists” and “Springing Granny”, as if the care home staff are cruel or indifferent, and running the care homes like prisons.

Well before the pandemic, care homes were under enormous pressure. Many were struggling to stay in business because of cuts to council budgets, meaning in turn that local authority fees don’t cover running costs. This meant that “self-funding” residents who pass the financial eligibility threshold were paying higher fees to cross subsidise the state funded residents.  

There were 1 in 8 unfilled vacancies in the social care workforce with neighbouring employees—not least the local NHS often poaching staff via better pay and conditions. The Home Office’s new points based immigration rules deliberately excluded social care staff from any visa exemptions as key workers, while acknowledging that their wages were low and care work was difficult.

In January, the UK prime minister Boris Johnson pledged to find a sustainable cross party solution to social care funding and provision within the following 12 months. To say that he has been a bit distracted since, is an understatement. The pandemic has left the treasury with competing calls on its largesse.

I’d be very surprised if he honoured his pledge. Meanwhile, some of our most dependent, disabled, medically needy citizens, including our own relatives and those of our friends and family, have been dragged belatedly into the spotlight by covid-19, but risk disappearing into the shadows once the pandemic is done. We can’t let that happen to them, nor to the often amazing staff who care for them. Their jobs may be low wage and undervalued, but they are not low skilled or unneeded.

David Oliver is an NHS consultant physician, a former Department of Health National Clinical Director, ex President of the British Geriatrics Society and Vice President of the Royal College of Physicians. 

Competing interests: See www.bmj.com/about-bmj/freelance-contributors.