Tory government guidance, 2 April 2020 – ‘negative tests are not required prior to transfers / admissions into the care home’

Long read – the perspectives you won’t get from BBC Scotland!

By stewartb

There continues to be much coverage regarding the Scottish Government’s handling of the Coronavirus pandemic as it affected the vulnerable in care homes. There is a relentlessness in the negative commentary on this subject in the corporate media and the BBC, and by political opponents.

Despite the research evidence referred to frequently here on Talking up Scotland, the chosen point of ‘attack’ is often the practice of discharge from hospital to care homes during the first wave of Covid cases in spring 2020.

Both the FM and Health Secretary have admitted that mistakes, with hindsight, were made back then in the handling of the pandemic within care homes. But with no incentive to provide any perspective – either from what happened in the rest of the UK or internationally – a view could take hold that Scotland’s government was exceptional in its actions – in these being different from and very much worse than their UK and international peers. This is presumably the intention. But it is very far from being the case. The purpose of this post is to provide additional information and insight – to provide perspective.

(In reading what follows, anyone who listened to Douglas Ross commenting on hospital discharges to care homes during Reporting Scotland on 19 April may recognise Tory hypocrisy! And that other commentator on the same programme, the Scottish labour leader Anas Sarwar, appears to have blocked out how his party in government in Wales handled care homes during the pandemic.)

Westminster and hospital discharge

The House of Commons Library issued a briefing paper relevant to this matter last month. It acknowledges there “has been considerable discussion regarding the discharging of Covid-positive patients from hospitals into care homes, including the possible role this may have played in introducing and spreading the virus in care homes.”  It examines the time line for the changing nature of the pertinent UK government guidance over time during the first wave of virus infection.

Source: HoCL (2021) Coronavirus: Adult social care key issues and sources. Briefing Paper No. 9019, 30 March 2021.

25 February 2020: As a baseline, guidance for social or community care and residential settings was published by Public Health England on 25 February 2020. The HoCL notes: ‘The guidance stated that it was “intended for the current position in the UK where there is currently no transmission of COVID-19 in the community. It is therefore very unlikely that anyone receiving care in a care home or the community will become infected.” Based on this position, it added that there was “no need to do anything differently in any care setting at present.” 

17 March 2020: NHS England and NHS Improvement instructed NHS trusts to “urgently discharge all hospital inpatients who are medically fit to leave” in order to maximise inpatients and critical care capacity. Further information on the processes to be followed was set out in guidance published by DHSC on 19 March: Coronavirus (COVID-19): hospital discharge service requirements.

2 April 2020: the UK government published guidance on the admission and care of people in care homes during the coronavirus outbreak. The guidance noted the role of the care sector “in accepting patients as they are discharged from hospital” and stated that “some of these patients may have COVID-19, whether symptomatic or asymptomatic”. It added that “all of these patients can be safely cared for in a care home if this guidance is followed.”

Annex C of the guidance provides more information on the isolation of residents, which can include the cohorting of all symptomatic residents if there is more than one case.

The guidance also stated that “negative tests are not required prior to transfers / admissions into the care home”.

An article published on the Times website in July 2020, stated, based on freedom of information requests to NHS trusts and boards, that two thirds of elderly patients discharged from hospital to care homes between mid-March and mid- April 2020 were not tested for coronavirus.

Insights from other sources

Perspective 1 – admission by a Prime Minister

Source: BBC News website 19 May 2020

Headline: ‘Coronavirus: What’s going wrong in Sweden’s care homes?’

“We did not manage to protect the most vulnerable people, the most elderly, despite our best intentions,” Prime Minister Stefan Löfven admitted last week.

‘The Swedish Public Health Agency told the BBC that 48.9% of deaths were care home residents up to and including 14 May.’

Perspective 2 – a major fail across Europe and beyond

Source: The Guardian 16 May 2020

Headline: ‘Across the world, figures reveal horrific toll of care home deaths”

Sweden: “Sweden’s health authorities are blaming the country’s death toll – which is higher than in neighbouring Denmark, Norway and Finland – on the fatality rate in care homes.”

Belgium: “More than half of the country’s coronavirus victims have died in care homes. Care home workers say the sector was initially overlooked, and they suffered from shortages of masks and skyrocketing prices for hand sanitiser.”

Spain: “In Madrid, the total for Covid, or suspected Covid, deaths since 8 March stood at 5,886 on Thursday. In Catalonia, it was 3,375. Between them, care home deaths in the two regions account for more than a third of all the coronavirus deaths in the country.”

Italy: “The prime focus was on a care home in Milan, which had more than 1,000 residents and where there was an unusual increase in deaths in March. An investigation began, and care home officials found that 300 residents had died between January and April.” And “Of the 900 residents still in the home, 34% were positive for Covid-19. Italy’s higher health institute found that between 1 February and 17 April there had been 6,773 deaths across all care homes, 40% of which were due to Covid-19.”

USA: “Residents of nursing homes have accounted for a staggering proportion of Covid-19 deaths in the US, where more than 85,000 people have died. Privately compiled data shows that such deaths now account for more than half of all fatalities in 14 states, according to the Kaiser Family Foundation. But only 33 states report nursing home-related deaths, so the true extent of the problem across the state remains unknown.”

Perspective 3 – a complex of causes

Source: Carl Heneghan and Tom Jefferson( 2020) ‘Dying of neglect: the other Covid care home scandal: Out of sight, the elderly have remained out of mind during this crisis. The Spectator, 6 June 2020

“It is remarkable how many deaths during this pandemic have occurred in care homes. According to the Office for National Statistics, nearly 50,000 care home deaths were registered in the 11 weeks up to 22 May in England and Wales — 25,000 more than you would expect at this time of the year. Two out of five care homes in England have had a coronavirus outbreak; in the north-east, it’s half.”

“… This is not just a British phenomenon, but one seen across Europe.”

“The Covid-19 crisis has placed extra demands on care homes, many of which were already inadequately staffed after years of underfunding. Across Europe, as in Britain, outsourcing to private contractors (in many cases private equity firms) led to cost-cutting. During the pandemic, many carers became immersed in attempts to prevent the spread of infection. Contact between carers and residents was reduced, often as a result of the lack of personal protective equipment (PPE). Less contact means less care and, therefore, more deaths.”

“In Spain, where two-thirds of the country’s fatalities have occurred in care homes, …”

“In the two weeks after lockdown, when the risk of infection should have been waning, a further 1,800 homes in England reported outbreaks.”

“Many homes were already not fit for purpose. The extra confinement which came with the Covid-19 panic has proved deadly. For the sake of a drink, in many cases, the elderly have died in their droves. We will, next time, learn lessons about what not to do. But we can help by being honest with ourselves about a scandal that is still ongoing.”

Perspective 4 –  scale and reasons in England and Wales

Source: Natasha Curry (2021) Beyond Covid-19 wave two: what now for care homes? Nuffield Trust blog (17 February, 2021)

The context for this Nuffield Trust blog post is: “.. the number of people residing in care homes in England and Wales to have died of or with Covid-19. Between mid-March and mid-June, there were 19,286 deaths of residents of care homes where the virus was mentioned on the death certificate, accounting for 40% of all Covid deaths registered in that period.” This is considered likely to be an underestimate of Covid related deaths.

The author asks: why were care homes hit so badly in wave one? Her response points to multiple factors:

• the care sector was already in a fragile state and was ill-equipped to cope with the sudden tide of infections. “Pre-existing workforce shortages, a vast and precarious provider market, long-standing financial shortfalls, and a lack of robust centralised data about who relies on care created a context in which a response to the virus was difficult to coordinate.”
• “A slow and uncoordinated national response led to delays in PPE supplies reaching care staff and in testing being rolled out.”
• “The drive to clear hospital beds in the first weeks failed to take account of the reality of the settings into which many people were being discharged.
• “Patients were not always tested before being discharged, and even when their Covid-19 status was known, the discharge wrongly assumed that care homes had the space, staff and resources to effectively isolate Covid-positive residents.”

The Nuffield Trust blog post asks: how have care homes in England and Wales fared in wave two? It refers to the following factors:

• at an early stage, efforts began to roll out faster testing, to deliver more reliable supplies of PPE and to issue timely and consistent advice to the sector, including reducing staff working across multiple care homes
• continuing challenges – reports of delays in testing and concerns about the practicalities of preventing staff working across settings

Nuffield Trust analysis of the mortality data for the second wave shows that, although there was a sharp rise in Covid-19 deaths among care homeresidents, the numbers so far have not reached the scale witnessed in the first wave. And even with a better testing regime, deaths from or with the virus among care home residents account for 26% of all Covid-related deaths in the period from 31 October until 5 February. “A marked improvement from the 40% of the first wave, but this still represents the devastating loss of over 16,000 individual lives so far.”

Perspective 5 – global view

Source: Wall Street Journal (2020) Covid-19 Stalked Nursing Homes Around the World – Government after government left frail residents vulnerable to pandemic; data review shows they accounted for over a third of fatalities in some countries (31 Dec. 31, 2020)

“A Wall Street Journal review of data from more than two dozen nations with significant elder-care facilities shows that such institutions are tied to more than a third of Covid-19 deaths, though they typically house less than 2% of the population. These countries linked at least 233,000 of 641,000 overall Covid-19 deaths to nursing homes and other long-term elder-care sites. In the U.S. alone, the death toll tied to these facilities tops 125,000.

“An analysis published in November in the Journal of Post-Acute and Long-Term Care Medicine looked at a dozen Organization for Economic Cooperation and Development member countries and found the Covid-19 mortality rate among long-term care residents was more than 20 times higher than that among older people living outside such facilities.

“We left the barn door open,” said Samir Sinha, director of health policy research and co-chair at the National Institute on Ageing, a think tank at Toronto’s Ryerson University which attributes more than 70% of Canada’s approximately 14,000 known Covid-19 deaths to long-term care homes.”

And on a very specific example: “Ann-Marie Riley, director of nursing at Walsall Healthcare NHS Trust, which manages the hospital where the elder Mrs. Keenan (a discharged patient with a positive Covid test) was treated, said at the time of her discharge Mrs. Keenan didn’t require high levels of care. As Mrs. Keenan was living with dementia, hospital staff made the clinical decision for her to return to familiar surroundings where she felt most comfortable, she added, noting that staff told her care home of her positive test result and it was happy to receive her and help her isolate.” (my emphasis)

“In the U.K., the rush was to protect the country’s National Health Service from being overwhelmed by Covid cases. The NHS told hospitals to discharge patients to clear up capacity, according to a report by the National Audit Office, which monitors government spending. Between March 17 and April 15, around 25,000 were sent to care homes without mandatory testing for the novel virus, the report said. The Department of Health and Social Care, the government department responsible for the NHS, said in June when the report was published that it made the right decisions at the right time and 60% of care homes avoided an outbreak.” (Douglas Ross clearly hadn’t read this in advance of his Reporting Scotland appearance this evening!)

Perspective 6 – in specific cases cause is unclear

Source: The Sun: CARE HOME TRAGEDY Covid kills HALF of care home’s residents over Christmas as boss says ‘we’re sitting ducks’ (Updated: 7 Jan 2021)

“CORONAVIRUS killed half of a care home’s residents over Christmas as a boss fears the elderly and staff are “sitting ducks” for catching the bug. Thirteen of 27 residents at Edendale Lodge care home in Crowhurst, East Sussex have died with confirmed or suspected Covid since December 13. The outbreak at the Sussex care home was detected by routine swab testing and none of the 14 residents who had tested positive had symptoms.

“Managing director Adam Hutchison said he doesn’t know how the virus entered the care home as they banned visits – apart from windows – and staff wore personal protective equipment. Agency staff who work at several homes were banned from entering. “It’s hard for me to say how it got in. Because of the protocols we were following, everything was there.”