Covid-19: why we need a national health and social care service
BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1465 (Published 14 April 2020) Cite this as: BMJ 2020;369:m1465Read our latest coverage of the coronavirus pandemic
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Dear Editor
I would like to thank the authors of this article for shining a light on the fragmentation of health and social care in the UK. The gaping holes in social care budgets, and lack of communication and coordination have been apparent to those working closely with community social services for years. Social care generally has become strained under austerity, leaving it with very little space to expand under the current crisis[1].
I would point readers to another group of patients, other than the elderly, who are reliant on social care for much of their needs; people who are homeless, and people who use drugs. Like the stark cuts to social care budgets and major privatisation of adult social care, community drug services suffered. As drug-related deaths rise, budgets suffered a loss of £162million between –2013/14 and 2017/18, an 18% cut[2]. One service in Worcestershire reported a 50% drop in budget during the same period, as drug-related deaths rose by 43% [2]. This is tragic without even the addition of the current crisis.
This population are socially excluded and thus are less likely to engage in public health measures and the positive community action which has come in the crisis. They are also more likely than the general population to have significant health conditions such a liver disease and respiratory conditions, placing them alongside the elderly as some of the most vulnerable to covid-19 [3]. Often for these populations self-isolation for 12 weeks is not an option. Even for those it is, this is fraught with previous experiences of trauma and the risk of unsafe withdrawals.
In this time of crisis, we should think about the most vulnerable in our society to adversity; those with additional social care needs. This is not just the elderly.
One of the key benefits of the national health service model used in the UK should be the ability of the health system to coordinate on a large scale to such crises as covid-19. Yet this is robbed by the fragmentation and budget siloing of social care, and systemic disinvestment. One of the key benefits of the health and social care act of 2012 was that it was supposed to enable local action, a “focus on public health” and a reduction in health inequality [4]. This emergency has proved that this is not the case.
Perhaps one of the things which will come out of the analysis of this country’s response to this pandemic is the tragedy that could have been avoided by removing the fragmentation between the health and social sectors. A country that prides itself on its NHS should not be shamed by its lack of support for social care and community services. Our immediate response should be to protect our society, but when the dust settles perhaps we should take at how we treat our most vulnerable.
[1] https://www.kingsfund.org.uk/blog/2020/04/health-social-care-covid-19-co...
[2] https://www.ukat.co.uk/addiction-treatment/ukat-campaign-reveals-cuts-ad...
[3] Schulte MT, Hser YI. Substance Use and Associated Health Conditions throughout the Lifespan. Public Health Rev. 2014;35(2) https://web-beta.archive.org/web/20150206061220/http://www.publichealthr...
Competing interests: No competing interests
Dear Editor
In high-income countries, concerns about large numbers of COVID-19 deaths in residential long-term facilities (LTFs) have been widely documented in the media and emerging academic literature [1]. It is likely that low and middle-income countries (LMICs) will eventually account for the majority of associated mortality, and, just as in high-income countries, deaths will be strongly concentrated among the oldest age groups [2].
The international literature and media have made virtually no reference to the specific risks posed to residents and staff based in similar facilities in LMICs. This reflects a general misconception that almost no older people in LMICs live in LTFS, reflecting strong social norms of intergenerational support and the wide availability of unpaid, largely female, family care [3].
Yet this is not the reality in many LMICs, especially in large urban centres. In Argentina, for example, the National Association of Long-Term Care Providers estimated that there were around 6,000 LTFs operating in the country in 2010 [4]. Many of these care homes operate informally, outside or on the fringes of legality, and subject to little if any regulation or quality assurance. Similar findings have been reported in other LMICs [5 and 6]. Responsibility is often divided between different local government departments (typically health and social development). There is growing evidence that conditions are often very poor and single bedrooms are a rare exception. These LTFs represent a very high risk environment for COVID-19 infection.
Some national and regional agencies are seeking to develop guidance for COVID-19 management in LTFs [7]. The World Health Organisation has provided some useful technical guidance for LTFs [8], but this is not always appropriate to the needs of many facilities, even in high-income countries, due to resources and space constraints [9]. Regardless of guideline suitability, the limited capacity of official regulators will reduce scope to implement or enforce them. There is emerging evidence from the field of widespread misinformation and inappropriate responses in these settings. We have received reports of LTFs which are yet to develop infection control protocols and other facilities which are denying family members all contact with or updates about residents (few of whom have access to telephones or computers).
There is an urgent need to rapidly upgrade the capacity of government agencies responsible for regulating LTFs in LMICs and to strengthen coordination when responsibilities are split. Where many LTFs are run on an informal, illegal basis, there may be a strong case to offer these facilities guaranteed amnesties from prosecution in exchange for cooperation in responding to the pandemic. There are precedents with previous collaborations between public health entities and illegal brothels to improve control of HIV and other sexually transmitted infections [10]. Also, regulators should hold urgent meetings with local LTF managers and civil society organisations representing the interests of older people, to ensure that key stakeholders participate in the development of local strategies. Where feasible, civil society organisations should seek to rapidly map LTFs and monitor in their locales, since many may not be on official registers. There is some evidence that this can be effective when deployed in combination with social media and online platforms [11].
More generally, across LMICS there is a need to overcome widespread denial about growing numbers of LTFs and the low quality of care they sometimes provide. The current crisis may represent an opportunity to increase the profile of this issue among policy-makers and to develop effective regulation.
Co-authors: Joao Bastos Freire Neto, Adelina Comas-Herrera and Nelida Redondo.
References.
1. Kimball A, Hatfield KM, Arons M, et al. Asymptomatic and Presymptomatic SARS-CoV-2 Infections in Residents of a Long-Term Care Skilled Nursing Facility — King County, Washington, March 2020. MMWR Morb Mortal Wkly Rep. ePub: 27 March 2020. DOI: http://dx.doi.org/10.15585/mmwr.mm6913e1external icon [accessed 8.4.20].
2. Lloyd-Sherlock P, Ebrahim S, Geffen L, McKee M Bearing the brunt of covid-19: older people in low and middle income countries. BMJ. 2020 Mar 13;368:m1052.
3. UN Women Long-term care for older people: A new global gender priority. https://www.unwomen.org/en/digital-library/publications/2017/12/long-ter... [accessed 8.4.20].
4. Lloyd-Sherlock P, Penhale B, Redondo N. The Admission of Older People Into Residential Care Homes in Argentina: Coercion and Human Rights Abuse. Gerontologist. 2019 Jul 16;59(4):610-618.
5. P.Lloyd-Sherlock, S.Sasat, A.Sanee, Y.Miyoshi, S. Lee The rapid expansion of residential long-term care services in Bangkok: a challenge for regulation. School of International Development, University of East Anglia, Working Paper 55. https://www.uea.ac.uk/documents/6347571/6504346/WP-55/2a384864-5397-53e6... [accessed 8.4.20].
6. P.Lloyd-Sherlock Long-term care and human rights violation in South Africa: the tip of an iceberg? BMJ 2016;354:i5126.
7. Economic Commission for Latin America and the Caribbean COVID-19 Recomendaciones generales para la atención a personas mayores desde una perspectiva de derechos humanos https://www.cepal.org/es/publicaciones/45316-covid-19-recomendaciones-ge... [accessed 8.4.20].
8. World Health Organisation IPC guidance for long-term care facilities in the context of COVID-19. https://apps.who.int/iris/bitstream/handle/10665/331508/WHO-2019-nCoV-IP... [accessed 8.4.20].
9. https://www.theguardian.com/world/2020/apr/08/canadian-nursing-home-reel... [accessed 8.4.20].
10. Ghose T, Swendeman DT, George SM. The role of brothels in reducing HIV risk in Sonagachi, India. Qual Health Res. 2011 May;21(5):587-600.
11. La Red Mayor http://www.redmayorlaplata.com/ [accessed 8.4.20].
Competing interests: No competing interests
Re: Covid-19: why we need a national health and social care service
Dear Editor,
Serious inadequacies in social care services represent a critical aspect also in Italy, especially with regards to women's safety and well-being.
It is known that crises, including health emergencies, further compound gender-based power dynamics and underlying inequalities in socio-economic and health systems, thus exacerbating violence against women, particularly when quarantine is involved. Confinement increases isolation for women with violent partners at a time when health systems are stretched to breaking point, and other protection services may be disrupted or difficult to reach.
D.I.R.E., the national network of shelters for women subjected to gender-based violence, released a shocking report in Mid-April:10 from the 2nd of March to the 5th of April 2020, 80 anti-violence shelters were contacted by 2867 women, which is an increase of 74.5% on the average monthly records (n=1643) when compared to the year 2018. Of concern is the fact that only 28.0% of the total requests (n=806) was represented by women who contacted such a network for the very first time in their life while in 2018 this proportion was as high as 78.0% (n=1288). This means that women are under constant control by their perpetrators and cannot reach out to services to ask for help.
When stratified by region, the large majority of women who seek help are from Lombardy and Tuscany, with more than 600 callers each, followed by Veneto, Friuli-Venezia-Giulia and Toscana. Seven femicides and three attempted femicides have been recorded in Italy since the beginning of quarantine, with 80% of them defined as domestic violence: all perpetrators were men in an intimate relation (husband, ex-husband, partners or ex-partners) with the victims (all women).
Never as before has a health emergency brought to the surface the close link between crisis and increase in violence against women and girls, as well as gender-based discriminations and abuse, not only on low and middle-income countries but across the globe.
We can state that COVID-19 and violence against women are an interrelated pandemic.
Availability, appropriate functioning and access to services should be ensured since the earliest stages of a crisis to minimize the risk to women and girls, who, in their turn, must be part of decision-making processes. Building resilient healthcare systems, reducing inequalities and vulnerabilities across gender and other variables like ethnicity, socio-economic status and geographic boundaries is key to avoid consequences related to violence against women.
Competing interests: No competing interests