One of the most sobering numbers to emerge from the first wave of the pandemic was 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. As described in our accompanying analysis of the most recent mortality data, this is likely to underestimate the true toll, as there were 35,067 excess deaths (deaths above the ‘expected’ number) of care home residents registered in this same period.
This devastating toll prompted calls for urgent action to be taken to better protect those in care homes ahead of subsequent waves. By mid-September, a winter plan for the social care sector had been published and by late October, the rapidly established social care taskforce had set out no fewer than 52 recommendations for protecting the sector in the next wave.
Why were care homes hit so badly in wave one?
The care sector was already in a fragile state going in to the pandemic 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. These pre-existing fault lines were laid bare during the early months of the pandemic. Gaps in knowledge about the sector were also revealed and still persist (one significant gap being that the impact of Covid on those receiving home care remains largely unmeasured and, particularly for people who fund their own care, currently unmeasurable).
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.
How have care homes fared in wave two?
As the second wave approached, 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. The extension of the infection control fund to late March 2021 (put in place until September 2020 initially) was welcomed, as was the pledge to supply the sector with PPE free of charge during the same period.
These efforts were not without their challenges, however, with reports of delays in testing and concerns about the practicalities of preventing staff working across settings. Severe restrictions on visits continue to be a source of deep distress to residents and families, and a complex balancing act of different risks for care home managers.
Our accompanying analysis of the most recent mortality data shows that, although there has been a sharp uptick in Covid-19 deaths among care home residents in this second wave, the numbers so far have not reached the scale witnessed in the first wave.
Even with a better testing regime, which is likely to be picking up more cases than was possible in the first wave, 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. Whether the measures taken prevented an even bigger loss of life, and to what extent other factors such as lower occupancy rates played a part, is impossible to say at this stage and warrants further study.*
What now for care homes?
The news that the first dose of the vaccine has now been offered to all care home residents is a relief, but it is not the time to be complacent. There are still many uncertainties about what impact the vaccine will have among the care home community, particularly in light of recent reports of vaccine hesitancy among staff. What is certain is that the need for vigilant infection control, PPE supplies and continued testing will not disappear any time soon. And while some lessons may have been learnt, care homes face tough times ahead.
Concerns around the financial stability of many care homes were raised before the pandemic, and the increased costs of PPE and staff sickness alongside lower occupancy rates have created extreme financial pressures. Although we haven’t yet seen the predicted widespread closure of providers, there is a risk that some care organisations are only just managing with the increased temporary pandemic support from the government.
Much of this support is set to end on 31 March and it is crucial that the care sector isn’t faced with a cliff-edge. The last thing users of care need after a traumatic year is to suffer the distress and disruption of their care home closing. Councils, providers, staff, residents and their families need certainty about what will happen come April.
Beyond that, as we begin to emerge from this pandemic, there is an opportunity to build something positive from the devastation of the last year by building a more sustainable and resilient care system, fit for the 21st century and better able to weather future storms.
*The Nuffield Trust is collaborating with LSE’s Care Policy & Evaluation Centre on an NIHR-funded study to better understand what we can learn from the Covid-19 experience in social care. The project will draw together learning from the experiences of other countries and their responses to the pandemic in social care. The aim is to inform policy and practice as the sector grapples with, and recovers, from Covid-19, and to put the sector on a more resilient footing for the longer term.
Curry N (2021) “Beyond Covid-19 wave two: what now for care homes?”, Nuffield Trust comment.