The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic had the unintended consequence of contributing to the spread of infection in care homes, say a group of cross party MP’s.
A report by a cross party group of MP’s, Coronavirus: Lessons learned to date - from the Health and Social Care Committee and the Science and Technology Committee has looked into the Governments response to the pandemic in England so far.
The report covers a variety of successes and failings during the COVID-19 pandemic, from the Government’s failure to do more to stop COVID spreading early in the pandemic to the success of the vaccination programme which they say was “one of the most effective initiatives in UK history”
Nearly 25% of all COVID deaths in the first year of the pandemic were among care home residents
Included in the 150 pages is 11 pages dedicated to the impact of COVID on the social care sector. Nearly a quarter of all COVID-19 deaths between 16th March 2020 and 30th April 2021 were among care home residents although the report recognises that this is likely to be an underestimate given the lack of testing of care home residents during the early weeks of the pandemic.
The report looked into several factors that affected the social care sector during the first year of the pandemic including the impact of protecting the NHS on Social Care, the discharge of patients to care homes during the first wave, infection and prevention control, visits in residential care settings and the underlying challenges already facing the social care sector. The committees have then given their recommendations and conclusions on how to ensure the social care sector is better supported moving forward.
Protect the NHS at the expense of Social Care?
Witnesses to the inquiry suggested that the Government’s emphasis on “protecting the NHS” first and foremost caused specific practical problems for social care providers. As Professor David Oliver, a consultant geriatrician and Nuffield Trust fellow put it: “Protect the NHS essentially meant protect the acute hospital bed base, with everything else a bit of an afterthought. That was a mistake.” This was echoed by other witnesses to the inquiry including Philip Scott, a family carer whose mother is a care home resident. He described feeling that care homes were “very much sidelined” during the first part of the pandemic.
Discharge of Patients to Care Homes in the first wave
The most damaging way in which the prioritisation of the NHS over social care manifested itself during the first wave of the pandemic was in the rapid discharge of people from hospital to care homes without adequate testing the report found. In order to free acute hospital beds in anticipation of the first wave of the pandemic, NHS providers were instructed to urgently discharge all medically fit patients as soon as it was clinically safe to do so, and care home residents were not tested on their discharge from hospital.
Around 25,000 people were discharged from hospitals into care homes between 17 March and 15 April 2020.
The inquiry also found that the impact of the pandemic on the social care workforce has also been acute. Between March 2020 and August 2020 7.5% of workdays were lost to sickness absence compared to 2.7% before the pandemic. During the course of the pandemic 74% of deaths recorded for social care workers had covid-19 recorded as a cause of death.
Infection prevention and control
The report found that there were several factors including lack of testing, inability to safely isolate patients, lack of access to PPE and movement of care home staff between homes during the early period of the pandemic which meant that it was not possible to safely discharge patients to care homes and at the same time avoid outbreaks of covid-19 within those homes.
The report found that both the Government and the NHS were slow to recognise this. Professor Martin Green, Chief Executive of Care England told the Health and Social Care Committee in May 2020 that guidance was “not really connected to the reality of lots of care homes” and was issued “for the perfect world” rather than the one we are in.
Professor David Oliver highlighted that this lack of awareness had also been an issue for the NHS, “There was not enough testing. There was not enough PPE in care homes or outside the PPE supply chain. Acute healthcare did not fully appreciate the limitations of trying to do infection control in care homes. Let’s face it, if we had a norovirus outbreak, a clostridium outbreak or a flu outbreak on a hospital ward that we can test for, we would not decant all of those people into care homes.”
Visits in residential care settings
Visits to residents of care homes were subject to severe restrictions for much of the first phase of the pandemic, causing great strain for residents and their family and friends. Care providers who gave evidence to the inquiry expressed a desire to enable visiting but highlighted the lack of resources and guidance to be able to do so.
Underlying challenges facing the care sector
The pandemic occurred against a backdrop of issues in social care including workforce shortages, funding pressures and provider instability which successive governments have failed to address. Even without the factors explored above, these long-term issues meant that the sector entered the pandemic in a weakened state which hampered its ability to respond to the impact of covid.
Jane Townson described home care as “[coming] into the pandemic with low status and in a weakened condition”, the Local Government Association described adult social care services as being at “breaking point” prior to the pandemic, while Care England stated that “the adult social care sector was not in as good a shape as it could have been due to the long term neglect of the sector”.
The social care workforce
As noted above, the social care workforce entered the pandemic in a weakened state. In 2019–20, there was an estimated vacancy rate of 7.3% across the year, equating to 112,000 vacant roles. The turnover rate was 30.4%, and around a quarter of the workforce (24%) were employed on a zero-hours contract. While pay has increased since the introduction of the National Living Wage, care workers continue to be low paid, with the average pay of retail assistants and cleaners having overtaken care workers in 2019–20.
Conclusions and recommendations
- The covid-19 pandemic has put massive strain on a social care sector already under huge pressure, which has a particular focus on caring for elderly people who have been at the greatest risk of death from covid.
- Social care had a less prominent voice in Government during the early stages of the pandemic than did the NHS.
- The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering care homes, and the failure to recognise this risk early is a symptom of the inadequate initial focus on social care. The lack of available testing at the time meant that the extent of spread by each route of transmission cannot be fully known and has not been conclusively determined by the report commissioned from PHE by the Government.
- Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and providing domiciliary care worked under strenuous conditions, at risk to themselves, to provide care to people.
- Many of these pressures on the social care sector—such as funding and workforce—are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in the social care sector must be fully vaccinated to continue to provide care in residential care homes.
Recommendations and lessons learned
- Planning for future pandemics should have a more developed and explicit consideration of the intense interaction between the NHS and social care. The prominence of social care within the Department of Health and Social Care should be enhanced and Ministers must address the relative lack of knowledge and experience of social care within the Department and senior levels of the NHS. The Department should ensure that future policy and guidance relating to the sector is well-informed and reflects the diversity of the sector. The Department must also set out how it plans to retain the expertise of the Social Care Taskforce on a more permanent basis.
- Long term reform of social care is overdue and should be pursued as a matter of urgency. The Government’s recent announcement on the future of social care is welcome, but the long-term future of the sector remains unresolved. We endorse the Health and Social Care Committee’s call for a 10 Year Plan for Social Care to accompany the 10 Year Plan for the NHS. It must ensure that there is parity between the health and care sectors so that social care is given proper priority in a future crisis.
- We endorse the Health and Social Care Committee’s call for additional resources to be directed to social care. That Committee has made the case for an increase of £7 billion a year by 2023/4.
- We note that despite the Government’s recent announcement the level of new investment in social care from 2023/24 remains unclear.
- The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills.
- The Government must ensure that care homes have isolation facilities and social care providers are able to provide safe visiting for family and friends of care home residents.
You can download the full report: Coronavirus: Lessons learned to date here.