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Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?

Authors:

Selina Rajan ,

The London School of Hygiene and Tropical Medicine, GB
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Adelina Comas-Herrera,

The London School of Economics, GB
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Martin Mckee

The London School of Hygiene and Tropical Medicine, GB
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Abstract

Context: COVID-19 has disproportionately impacted mortality in English care homes.

Objectives: To examine COVID-19 policies for care homes in England and to describe providers’ experiences of those policies in May and June 2020.

Methods: Mixed methods including policy analysis and an anonymous online survey of English care home providers, recruited using webinars and WhatsApp groups about their experiences of funding, testing, PPE, isolation and staffing until the end of May and early June 2020.

Findings: Although social care policies in England have aligned with those advised by the World Health Organization, they were arguably delayed and were not implemented effectively. Testing had taken place in 70% of care homes surveyed but only 36% of residents had been tested, of whom 16% were positive. Managers were unable to effectively implement isolation policies and reported that workforce and funding support did not always reach them. Guidance changed frequently and was conflicting and could not always be implemented, for example when personal protection equipment was extremely expensive and difficult to source.

Limitations: Although this was not a representative sample, care homes responded from across the country and we report the most consistent themes. Potentially, care homes that found it harder to implement national guidance may have been more inclined to respond to our survey than those who more easily changed practice, although those with outbreaks may also have had less capacity to respond. Some aspects of policy will have also changed since early June.

Implications: Despite policies that were put in place, care homes amongst our survey respondents were still unable to access sufficient funding, testing, PPE, workforce support and practical support to isolate residents by the end of May and early June. Future cross-country policy analyses must examine policy implementation as well as content.

How to Cite: Rajan, S., Comas-Herrera, A. and Mckee, M., 2020. Did the UK Government Really Throw a Protective Ring Around Care Homes in the COVID-19 Pandemic?. Journal of Long-Term Care, (2020), pp.185–195. DOI: http://doi.org/10.31389/jltc.53
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  Published on 11 Nov 2020
 Accepted on 27 Oct 2020            Submitted on 03 Sep 2020

Introduction

The first cases of COVID-19 in care homes in England were reported in the second week of March 2020. By the end of July there had been nearly 7,000 care home outbreaks in England, with more than three quarters occurring before the end of April (Public Health England, 2020e). Between the 2nd of March and the 20th of June, English care homes registered 66,112 deaths (Office for National Statistics, 2020), of which 29% were registered as COVID-19 deaths. Between weeks 11 and 26 (ending 26th of June), mortality in care homes compared to previous years had increased by 79% in England, 62% in Scotland and 66% in Wales (Bell, Comas-Herrera, Henderson, et al., 2020). The proportion of care home residents who died was also second highest in the UK compared to other countries in Europe (Comas-Herrera, Zalakaín, et al., 2020) and the reasons for this are disputed. The UK’s Health and Social Care Secretary, responsible primarily for the situation in England as both health and social care are the responsibility of the devolved administrations in Scotland, Wales, and Northern Ireland, claimed that the government had “tried to throw a protective ring” around care homes (The Financial Times, 2020) but the Prime Minister argued that “too many care homes didn’t really follow the procedures” (Walker, Proctor and Syal, 2020). Here, we examine the policies set out by the government and contrast them with the experiences reported by care home providers during end of May and early June 2020.

Methods

We conducted a mixed methods study, starting by identifying the range of measures recommended and adopted internationally to address COVID-19 in care homes in England (Comas-Herrera, Ashcroft, et al., 2020; World Health Organization, 2020; World Health Organization Regional Office for Europe, 2020). These include the provision of additional funds; testing and contact tracing in care homes; ensuring access to personal protective equipment (PPE) and other equipment; limiting visitors and new admissions; isolating all new admissions (inside or outside the care home); preparing additional isolation facilities for suspected or confirmed cases; recruiting additional staff (including healthcare staff) where there were high levels of staff absence or of unwell residents; avoidance of staff working across multiple facilities; development of guidance and training in infection prevention and control.

We then reviewed policy documents and grey literature to identify the measures and policies announced for care homes in England by early June and mapped those against data on the number of outbreaks and deaths in care homes.

We worked with care providers and representatives from the National Care Forum to co-design a survey based on a number of themes they identified as priorities. These included funding, testing, PPE and infection control, isolation and visitation, and staffing. The survey methods are described in detail elsewhere (Rajan and Mckee, 2020), but briefly, between the 15th of May and the 12th of June 2020, we invited directors and managers of care homes that participated in webinars and WhatsApp groups to take part in an anonymous survey. All were members of the Spectrum Consortium or the Care Leaders Network respectively. The survey sought their experiences in obtaining support from health and social care bodies during the pandemic, focussing on the key issues that the care home representatives had identified. These networks include several hundred care home providers in England in total. The aim was not to establish a representative sample but to identify overall themes from their experiences.

Finally, we analysed the experiences of the directors and managers of care homes against the announced policies for each of the themes.

Results

Figure 1 shows a timeline of national care home policies in England alongside the numbers of outbreaks and deaths using data from Public Health England (Public Health England, 2020e) and the Office for National Statistics (Office for National Statistics, 2020).

Figure 1 

Timeline of English policies in relation to weekly COVID-19 outbreaks and cumulative COVID-19 deaths in care homes.

We received responses from 35 care home directors and 43 care home managers representing a total bed capacity of 1,330 beds, of which 1,311 were occupied between December 2019 and March 2020. Care homes responded from across England, coming from 27 different Local Authorities (of 152 with responsibility for adult social care). The characteristics of these homes are reported in Table 1 and described in more detail elsewhere (Rajan and Mckee, 2020). The median capacity was 27 residents (IQR 17–37) and 58% of participating care homes were part of a group, of which 56% included 5 or fewer care homes. 37% were nursing homes, 88% cared for adults over the age of 65 and 65% for those with dementia. 93% were reliant on local authority funding and 86% also had self-funded clients (i.e. those who pay for their own care because they are not eligible for state-funded care).

Table 1

Baseline Characteristics of Participating Care homes and Access to and Results of COVID-19 Swab Testing.

Managers
N = 43

Group Size*
Not part of a group 18 (42%)
1–5 homes 14 (33%)
6–10 homes 7 (16%)
11–50 homes 4 (9%)
CQC Registration Type*
With nursing 16 (37%)
Without nursing 27 (63%)
Type of Services
Adults under 65 15 (35%)
Adults over 65 38 (88%)
Physical disability 27 (63%)
Learning disabilities 11 (26%)
Mental health conditions 12 (28%)
Sensory Impairments 11 (26%)
Dementia 28 (65%)
Behaviour that can challenge 1 (2%)
Funding sources
Local authorities 40 (93%)
NHS and clinical commissioning groups 24 (56%)
Self-funders 37 (86%)
Not for profit 1 (2%)
Occupancy
Median bed capacity (IQR) 29 (17–40)
Median % occupancy, Dec 19–Mar 20 (IQR) 92% (81%–97%)
Median % occupancy, current (IQR) 80% (74%–93%)
Median drop in % occupancy (IQR) 8% (6%–10%)
Closed to visitors before March 17th 18 (45%)
Resident cases and testing
Any resident testing 30 (70%)
At least one suspected case 24 (56%)
Have tested asymptomatic residents 18 (42%)
All residents tested 4 (9%)
At least one confirmed case 16 (37%)
At least one COVID-19 death (based on death certificate) 13 (33%)
Staff testing
Have tested asymptomatic staff 22 (51%)

* Options were mutually exclusive.

We have structured our results around the five survey themes identified by care home representatives (funding policies, testing, personal protection equipment and infection control, isolation and visitation, and staffing). For each, we set out the policy context, indicating the intended measures, and then report the results of our survey.

Funding policies

On the 13th of March the government announced extra resources to tackle COVID-19, with £3.2 billion additional funding to support local authorities (who commission adult social care services for those eligible for state funded care), including for emergency provision of PPE (Public Health England, 2020c). Nearly two months later, the government announced that PPE would be zero-rated for Value Added Tax (VAT), initially until July but subsequently extended to October 2020. On the 14th of May (Whately, 2020) the government announced an additional £600 million for a new Infection Control Fund, allocated to Local Authorities to pay the care sector for efforts to minimise staff transmission, although this did not include PPE (Department of Health and Social Care, 2020a).

Funding survey results

PPE had a major impact on costs of care, with 91% of directors in our survey reporting that costs of disposable and reusable supplies had increased, while 63% also described increased staffing and agency costs, with some stating that staffing agencies had inflated their costs. One director said “The cost of PPE has increased astronomically. For example, 800 aprons from our supplier used to cost approximately £9. One thousand of the same aprons now cost £43. These costs are simply not sustainable. Our usual provider is now unable to source some PPE and we are now forced to spend even more than the already inflated prices.” Despite the marked inflation in PPE costs, only 30% of care home managers in our survey had received a financial uplift at the time of the survey with 73% stating that they needed more funding. 69% of directors we surveyed also described a fall in occupancy since February, with multiple COVID-19 deaths and reduced admissions resulting in empty unfunded beds. Of those surveyed, 80% of care home managers had not received additional funding to cover this fall in occupancy, and a third of directors commented on inconsistencies between different Local Authorities, with many refraining from paying. According to one director, “many operators struggle financially and may go bust.”

Testing Policies

Initially national policies on testing care home residents were lacking and only those who had travelled abroad were considered to be at sufficiently high risk to require testing. Testing was first mentioned in social care guidance on the 13th of March (Public Health England, 2020c), but was limited to a maximum of 5 symptomatic residents in each home (Dunn et al., 2020). Initially testing was organised by Public Health England’s health protection teams, triggered by notification of 2 or more suspected cases, although this was not contained in contemporary guidance (Public Health England, 2020c). By the 8th of April, all additional symptomatic staff and residents were offered testing but formal acknowledgement of this policy awaited publication of the Adult Social Care Plan on the 16th of April (UK Government, 2020a) and none of these care homes were formally followed up by outbreak teams. Instead, newly identified cases were reported to the Care Quality Commission (CQC) (the regulator for the sector), who usually record adverse events with implications for quality of care rather than public health events requiring investigation. Meanwhile, the Scientific Advisory Group for Emergencies (SAGE), which advises the government, had identified the potential for asymptomatic transmission as early as the 28th of January and when it had become clear in March that asymptomatic infection was likely to be common in care home residents (McMichael et al., 2020), they also discussed the evidence for mass and pooled testing on the 21st of April (Smith et al., 2020) In a press briefing on the 28th of April, the government announced whole home mass testing for all care homes containing older residents and those with dementia, by which stage, nearly 80% of all outbreaks recorded by mid-July had already taken place (Public Health England, 2020e). Guidance about who care home providers should test and when, how to maintain safe staffing levels in the event of mass absenteeism, and what to do with positive results was not published until 19th of June (Public Health England, 2020b).

Testing survey results

By the end of May and early June, only 4 (10%) care homes in our survey had tested all of their residents, with only partial testing in other homes. Table 2 shows that testing had taken place in 30 (70%) care homes, where 105 symptomatic and 307 asymptomatic residents were tested, accounting for 45% (31%–59%) of the 912 residents in these homes and 36% (95% CI 25%–48%) of all 1,311 residents in the survey. Of those 412 tests, 69 cases were confirmed in 16 (37%) care homes, producing a positivity rate of 17% (95% CI 6%–28%). Symptomatic residents were identified in 24 (56%) care homes where 145 out of all 745 (19% (95% CI 13%–26%) residents had symptoms. Of these, 72% (95% CI 58%–87%)) were tested, of which 47 (45% (95% CI 25%–65%) were positive. Asymptomatic resident testing was only reported by 18 (42%) care homes, where 59% (95% CI 38%–80%) of residents (307 out of 521) were tested (excluding symptomatic cases), of which 22 (7% (95% CI –2%–16%)) tested positive in 5 (28%) homes. Overall, 32% (95% CI 6%–57%) of all confirmed resident cases were asymptomatic at the time of testing, of whom 2 (9%) subsequently developed symptoms. Twenty-two (55%) homes had tested asymptomatic staff, with 4% (95% CI 0.4%–9%)) testing positive (9 out of 215) in 5 (23%) care homes. Of those, 4 (45%) subsequently developed symptoms.

Table 2

Proportion of symptomatic and asymptomatic residents who were tested.

Total Care Homes (N = 43) No. of Residents Susceptible (N = 1,311) No. of Individuals Prevalence (95% CI)

All Residents
Any resident testing 30 (70%) 912 412 45% (31%–59%)
Confirmed Cases 16 (37%) 912 69 8% (3%–12%)
    Positivity rate 17% (6%–28%)
Symptomatic residents
Symptomatic residents 24 (56%) 745 145 19% (13%–26%)
Symptomatic residents that were tested 21 (49%) 655 105 16% (10%–22%)
Confirmed symptomatic cases 15 (35%) 655 47 7% (4%–11%)
    Positivity rate 45% (25%–65%)
Asymptomatic Residents (hot and cold homes)
Asymptomatic residents that were tested 18 (42%) 521 307 59% (38%–80%)
Asymptomatic confirmed cases 5 (12%) 521 22 4% (–1%–9%)
    Positivity rate 7% (–2%–16%)
    No. cases who later developed symptoms 22 2 9%
% of confirmed resident cases that were asymptomatic 32% (6%–57%)
Staff
Asymptomatic + tested 22 (51%) N/A 215 N/A
Asymptomatic confirmed cases 5 (12%) N/A 9 N/A
    Positivity rate 4% (0.4%–9%)
    No. cases who later developed symptoms 4 (45%)

PPE and infection control policies

Infection control guidance was first published in early January (Public Health England, 2020d) and was updated 30 times by mid June, sometimes daily. Guidance published on the 25th of February (Public Health England, 2020a) explicitly advised against use of facemasks in care homes, which were not advised until the 13th of March (Public Health England, 2020c), when they were only advised for symptomatic residents. At this time, the government issued 300 free masks from the influenza pandemic stockpile to every CQC registered care home to support them to comply with the new guidance. On the 10th of April a new PPE plan was published, alongside additional guidance, now recommending use of PPE for contact with any residents, regardless of symptoms, as community transmission was now deemed to be sustained. This was accompanied by an announcement that more PPE would be released to local resilience forums for distribution as needed, with additional supplies released to designated wholesalers for care homes to purchase. The plan also promised the development of a Parallel Supply Chain to be operated by the army, which would “push” PPE products to care homes according to need. This was not mentioned again until the 5th June (Department of Health and Social Care, 2020b) when it was announced that this would only be an emergency source of PPE.

PPE and infection control survey results

62% of managers in our survey reported that they had always had enough PPE, and only 5% could recall a time when PPE had been completely unavailable to their homes (Table 3). However, directors reported that this was only achieved because they paid inflated prices. 63% of managers reported that Local Authority provision of emergency PPE had been useful, but 68% reported needing more support to procure PPE. A more detailed analysis showed how directors procured PPE from many sources, with 69% using government wholesalers, 29% relying at times on local resilience forums for emergency supplies, and 34% sourcing PPE from abroad (Rajan and Mckee, 2020). 79% had struggled to source facemasks, and around half encountered challenges procuring gloves, aprons and hand sanitizer (Rajan and Mckee, 2020). 74% of managers also reported that frequent changes in infection control guidance were particularly challenging, with 67% of managers reporting inconsistencies in government guidance, and conflicts with many local health and social care departments who often issued their own policies.

Table 3

Care Home Managers’ Experiences of the Policies for PPE and Isolation and Workforce Challenges.

Managers

Concerns providing PPE* (N = 43)
Always had enough 27 (63%)
Yes <7 days’ supply at times 14 (33%)
Yes <24 hrs supply at times 0 (0%)
Yes – completely unavailable at times 2 (5%)
Isolation of residents with suspected COVID-19 (N = 40)
Not able to 10 (25%)
Able to but didn’t 3 (8%)
Able to and did but not always possible 14 (35%)
Able to and always did 13 (33%)
Challenges implementing PHE infection control guidance (N = 43)
Understanding and applying guidance 10 (23%)
Conflicting guidance from different organisations 29 (67%)
Keeping up with frequent changes to guidance 32 (74%)
Insufficient testing for atypical presentations 18 (42%)
Inability to isolate residents who walk with purpose 20 (47%)
Managing admissions from hospitals 10 (23%)
Managing visitors 6 (14%)
Greatest workforce challenges (N = 41)
At least one staff member isolated with symptoms 31 (70%)
Morale, mental health and wellbeing 30 (73%)
Staffing Shortages 16 (39%)
Access to and interpretation of COVID-19 tests 22 (54%)
Staff training 6 (15%)
Provision of occupational health services 3 (7%)
Providing accommodation for staff 2 (5%)
Other 10 (26%)
Have you observed any of the following in residents following isolation for COVID-19? (N = 33)
Low mood and agitation 28 (85%)
Pressure sores 1 (3%)
Increased falls 2 (6%)
Reduced mobility 4 (12%)
Reduced oral intake/weight loss 10 (30%)
None 4 (12%)
What factors have influenced resident wellbeing during the COVID-19 pandemic? (N = 42)
Reduced access to clinical support for residents 15 (36%)
Fewer activities 22 (52%)
Fewer social interactions from visitors and other residents 41 (98%)
Disrupted routines e.g. mealtimes 6 (14%)
Impacts of PPE on relationships with care staff 20 (48%)
Other 2 (5%)

* Options were mutually exclusive.

Isolation and visitation policies

Isolation precautions were initially based on usual practice for influenza (Public Health England, 2020c). Staff would notify Public Health England Health Protection Teams about any cases with symptoms, and they would advise that resident and their contacts to isolate, although this was not clearly documented in guidance until the 2nd of April (Public Health England, 2020b). The Adult Social Care plan was published on the 16th of April (UK Government, 2020a), acknowledging that there may be some difficulties in isolating residents, stating that: “If appropriate isolation/cohorted care is not available with a local care provider, the individual’s local authority will be asked to secure alternative and appropriate accommodation and care for the remainder of the required isolation period” (section 1.32). It was suggested at the time that this be achieved in association with the NHS.

Prior to this, NHS guidance published on the 19th of March (UK Government, 2020b) called on hospitals to discharge residents to care homes to free up capacity, and care homes were reassured that it was safe to receive these patients without testing. It was not until the 2nd of April that mandatory isolation of admissions was introduced (Public Health England, 2020b).

In the early stages, visitation to care homes was only prohibited for people with symptoms of COVID-19 (Public Health England, 2020c) until the 16th of March, when physical distancing was announced, after which, all visits were prohibited and the Prime Minister warned against anyone visiting care homes unnecessarily (BBC News, 2020). On the 15th of April, the Secretary of State announced that families could now visit dying relatives in care homes where feasible, and this was subsequently confirmed in the Adult Social Care Plan (UK Government, 2020a).

Isolation and visitation survey results

60% of managers in our survey said that they had not always been able to isolate residents with suspected COVID-19, with 45% being unable to isolate residents who walked with purpose. 26% were unable to cohort residents, often because the home layout precluded the creation of separate units (Table 3). In reality, many care homes we surveyed had closed down by the 5th of February (irrespective of symptoms), and by the 30th of March all had closed to visitors (Figure 2). By the time physical distancing was announced in mid-March, 54% of homes in this survey had already closed to non-essential visits. This isolation had enormous impacts on residents according to care home managers: 84% reported low mood among residents, attributed predominantly to being deprived of visitors (98%) and fewer activities (54%), while 46% also commented on the impact of PPE on relationships with staff, while 28% reported reduced oral intake, and several described weight loss (Table 3).

Figure 2 

Dates when care homes closed to non-essential visitors.

Staffing policies

On the 13th of March, as a temporary measure, the government committed to paying for Statutory Sick Pay from day one of sickness to support those affected by COVID-19 (Public Health England, 2020c). As part of the Adult Social Care Plan in April they also announced an intention to launch a new social care recruitment campaign (UK Government, 2020a), subsequently offering Psychological First Aid training to frontline workers later on in June. The Adult Social Care Plan also committed to publishing more detailed guidance on the use of volunteers in care homes, but this has yet to materialise at the time of writing. Following a Public Health England whole home testing study in several care homes in London in April, which suggested that transmission had occurred between care homes, mediated by the increased use of bank staff, (Whately, 2020) it was proposed that the infection control fund should be used to pay the salaries of additional staff; to maintain the normal wages of staff who are self-isolating; and provide staff with accommodation and infection control training (Department of Health and Social Care, 2020a).

Staffing survey results

At least one staff member had isolated with symptoms of COVID-19 in 72% of care homes in our survey, including all of the homes with reported outbreaks. Staff were hospitalised in 3 (10%) facilities, with 1 (3%) reporting a death. As shown in Table 3, 43% of managers we surveyed reported staffing shortages and 1 in 3 described resorting to using agency staff, who accounted for between 2 and 37% of their workforce. Nearly half of directors in the survey also stated that they still needed support with surge staffing and described their frustrations with being unable to routinely test staff. 75% of managers also reported that they were concerned for the morale, mental health and wellbeing of their staff and 37% commented that the inability to access clinical support had impacted resident wellbeing.

Discussion

Key Findings

COVID-19 has disproportionately impacted mortality in care homes internationally and in that respect, England is no particular exception, with care home resident deaths accounting for approximately 46% of all COVID-19 mortality (Comas-Herrera, Zalakaín, et al., 2020). A brief look at the WHO policy recommendations (World Health Organization, 2020) suggests that on paper, the government has heeded advice to test, ensure access to PPE, limit visiting, isolate new admissions, bring in additional staff, avoid staff working across multiple facilities, provide infection control guidance and provide additional funds. However, in practice we found questions as to how promptly and effectively these had been written into guidance and/or implemented. Also, many of these decisions were arguably made very late by the government and some resources remained unavailable or hard to source to many providers in our survey. In addition, homes had difficulties with frequently changing, sometimes conflicting and often impractical guidance.

COVID-19 has magnified existing weaknesses in the English adult social care system’s support to care homes and, while the UK government announced a number of policies to mitigate the impacts of COVID-19 on English care home staff and residents, most were not announced until after the majority of outbreaks had already taken place and were inconsistently implemented. Delays to scaling up testing and the prioritisation of the NHS over social care have attracted much criticism, most recently by the Commons Health Select Committee (UK Government, 2020c) and the Public Accounts Committee (Public Accounts Committee, 2020). Despite the welcome announcements that the Department of Health and Social Care would provide whole home testing to care homes across the country, this was not fully implemented until June and only 40% of care homes represented in our survey had accessed any testing for asymptomatic residents by the end of May and early June when the peak had passed and reopening had already begun. Despite this, we found that nearly one in six residents who were swabbed tested positive for COVID-19 at the time of testing, and a third were infected without displaying symptoms, reinforcing the need for ongoing surveillance. Some ministers have justified late policy decisions as a response to early uncertainties about asymptomatic transmission, although evidence to support concern about this was published as early as January 2020 (Arons et al., 2020; Rothe et al., 2020). In July, the government announced that all staff and residents in care homes for over 65s or those with dementia would be regularly tested for COVID-19, but confirmed several weeks later that this would no longer be feasible before September. Instead, they committed in early August to providing rapid point of care testing within a week, using tests that were to be validated during role out, but this had yet to materialise by September (UK Government, 2020d). Blanket swab testing is particularly time-consuming for care homes and there is still minimal evidence about the degree to which asymptomatic cases contribute to transmission. The situation in care homes in September remains tenuous, with many starting to open up to visitors, on the government’s advice, without reliable access to repeated testing. Elsewhere we report data from our survey showing that trust by care home managers and directors in the government has deteriorated (Rajan and Mckee, 2020).

There has been a great deal of media attention on the poor access that social care providers had to a robust PPE supply chain, and it is also not known whether the delay in advising the routine use of PPE in care homes to account for asymptomatic transmission placed residents and social care workers at increased risk of mortality. Inevitably, the frequent and unannounced changes to guidance left providers in a challenging position, competing with one another for PPE supplies at rapidly increasing costs. While it is unsurprising that demand would outstrip supply in a pandemic situation, evidence highlights a failure of government to replenish influenza stockpiles (Dunn et al., 2020) and as yet, there is no evidence that the supply chain of PPE to care homes will cope if there is a sudden resurgence of cases in winter.

Unsurprisingly, workforce shortages were an immense challenge, with many care home managers using agency staff to cover absences, and there was widespread concern about staff mental health and wellbeing. Although political rhetoric emphasised recruiting more NHS staff during the pandemic, England entered the pandemic with 122,000 vacancies in social care (Skills for Care, 2019), which are unlikely to be meaningfully addressed by a campaign to recruit 20,000 people. While the publication of the NHS People’s Plan is welcome, there is now a very urgent need to provide a clear plan for workforce recruitment, welfare, and development in adult social care.

The lack of clear guidance on visitors confused care home managers, many of whom closed to visitors long before the government imposed physical distancing. Although guidance around the safe reopening of care homes to visitors was not published until the 22nd of July (Department of Health and Social Care, 2020c), many providers did not wait, turning instead to the Care Providers Alliance (an umbrella organisation for adult social care providers) who supported them to reopen safely and cope with the inevitable psychological impacts on residents.

During the pandemic, residents experienced reduced access to healthcare, with falls in elective and emergency admissions to hospitals from care homes and a rise in admissions from hospitals to nursing homes (Hodgson et al., 2020). However there were some positive examples of work to improve health care for residents in the full survey report, such as the creation of local multi-disciplinary teams with health and social care working in partnership to find local solutions (Rajan and Mckee, 2020).

Isolating residents with suspected COVID-19 within the home was enormously challenging given home layouts and the large share of residents who walk with purpose and more than half of managers confirmed that they could not always isolate and cohort residents, where necessary. Prior to April 2nd, residents who were admitted to care homes from hospitals were not required to isolate, and it is plausible that this may have resulted in some increased transmission. Even after this advice was published, care home managers faced logistic, physical, and emotional challenges in isolating residents. Despite the recommendation for local authorities to provide quarantine facilities, it is not clear that this happened or that there is yet sufficient resource to implement this. In Singapore, where only 3 deaths have been recorded in care home residents so far, special quarantine facilities were provided to isolate suspected cases in long-term care facilities.

A formal inquiry may be required to discern the reasons for the delayed and poorly implemented government policies but it is likely that they were the product of both structural and socio-political factors (Daly, 2020). From the structural point of view, the social care sector is consistently excluded from health policies and services, which are rarely co-designed with either the sector or the residents who use them. The sector itself is diverse, and two-thirds are either small or not-for profit providers, without consistent support or representation (Devi et al., 2020). Following years of government underfunding and lack of public commitment to social care, some have suggested that policies for care homes may have been considered less politically important than those for the NHS (Daly, 2020). It is now expected that imminent reforms to funding, safety, and regulation of social care as well as its relationship with the NHS will be expedited, with the guidance of an Adult Social Care Taskforce. The content of these reforms is still unknown as is the extent to which they will be based on rigorous consultation with residents, relatives, providers and commissioners.

Strengths and Limitations

There is no other study we are aware of that has documented how government policies affected care home providers’ ability to respond to the pandemic, but there are several limitations to this research. This was not a representative sample of care homes from England and many homes did not respond amidst the emergency response. The survey may have attracted more response from care homes who struggled with the issues discussed above than from those who found it easier to adapt although those with outbreaks may also have had less capacity to respond. We have therefore extracted the most consistent themes that were reported by providers, rather than performing detailed quantitative analyses. Some aspects of policy will have also changed since early June.

Conclusion

The government’s policies and measures to protect people living in care homes and support providers did not succeed in providing a “protective ring around care homes.” Its policies were good on paper but were often too late and were neither communicated nor implemented adequately. Those running care homes in our survey felt unsupported in the first wave, especially with respect to accessing funds, testing, PPE, workforce support and practical support (such as additional quarantine facilities outside the homes where needed). This paper also highlights the danger of relying only on policy announcements to assess the degree to which countries have worked on mitigating COVID in care homes.

Acknowledgements

We would like to thank Hugh Mcneil from Cabot Square LLP and Dr Sanjiv Patel from Westgate Healthcare who helped us to test the surveys and Liz Jones, Director of Policy at the National Care Forum who also advised on the survey design.

Competing Interests

Selina Rajan is holds an honorary contract with Public Health England although receives no direct funding from them. Her family own 3 medium sized nursing homes in which she holds a small number of shares. We declare no other competing interests.

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