Intended for healthcare professionals

Letters Care homes after covid-19

Covid-19 in care homes: the many determinants of this perfect storm

BMJ 2020; 369 doi: (Published 27 May 2020) Cite this as: BMJ 2020;369:m2096
  1. Desmond O’Neill, professor of geriatric medicine
  1. Trinity Centre for Health Sciences, Tallaght University Hospital, Dublin D24 NR0A, Republic of Ireland
  1. doneill{at}

The concerns evoked by Oliver over care homes and covid-191 are echoed in the privatised, fragmented, and disconnected care or nursing home sectors in most Western countries. Media coverage has focused on the travails of care staff and residents rather than on the determinants of the crisis.

This perfect storm has been brewing for some time. Departments and ministries of health, charged with developing policy based on need, averted their gaze from this high need group and failed to develop networks with primary and secondary healthcare to meet these needs and to incorporate resilience for crises. This was compounded by a political thrust to offload services to the private sector without resolving how private and public services could work effectively together.

Pay and conditions in the private sector are less supportive of care staff, reflecting the lack of commentary about the moral responsibility of care home owners to ensure adequate care for their residents, support for staff, resilience for inevitable epidemics and pandemics, and clarity on the degree of profit making.

Commissioning agencies rarely incorporate gerontological expertise or match funding to developing residents’ needs in funding schemes. Regulatory agencies are not usually tasked with assessing the adequacy of clinical leadership, expertise, and resilience.

Professions most closely engaged with the sector on a daily basis have not distinguished themselves in actively developing policies and guidelines, perhaps relating to a complex mix of perceptions of status, worth, and rewards, as well as gerontological illiteracy.2

Given the ongoing need for new admissions to care homes in a pandemic that might last 12 to 18 months, we urgently need to resolve this longstanding policy failure crisis and to radically overhaul leadership (such as medical director roles3), care standards, staffing, expertise, and clarity on links to the broad range of specialist advice and services required.4


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