Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Let’s be open and honest about covid-19 deaths in care homes

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2334 (Published 18 June 2020) Cite this as: BMJ 2020;369:m2334

Read our latest coverage of the coronavirus pandemic

  1. David Oliver, consultant in geriatrics and internal medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com

    Follow David on Twitter: @mancunianmedic

From the first recorded UK case to June 5, the Office for National Statistics (ONS) reported 17 422 deaths of care home residents from covid-19 in England and Wales—47% of the total.1

England’s health secretary, Matt Hancock, was insisting in the media that only around 30% of deaths in England were in care homes, saying that it was lower than the European average, by using Department of Health and Social Care data based only on people who had tested positive for covid-19 (when tests were in short supply) rather than on death certification—an approach used by ministers throughout the pandemic.

Although the ONS started publishing the covid-19 data on deaths in all settings and excess all cause deaths on 13 March, there was a delay before they were included in the daily Downing Street briefings.

The daily death toll data from briefings were amplified by personal accounts from bereaved families who had not been able to be with their loved ones when they died. Care home managers and staff spoke out about being overwhelmed, becoming sick themselves, and the lack of adequate access to personal protective equipment or testing.23

Less often reported in the media was that care home residents are generally frail, entering the last year or two of their lives, and susceptible to any respiratory virus outbreak, with around a third of all residents dying each year.45 Also, that death rates in care homes can indeed be kept very low if all residents die in hospital wards instead.

Barely touched on in media reports were the concerted efforts over many years to ensure that care home residents could be supported there when sick or dying and not taken to busy, alienating hospitals; or the growing problem, before the pandemic, of people needing transfers back to care homes and being stranded in hospital, sometimes for weeks.67 Even before the pandemic, we in health and social care had repeatedly highlighted the crisis in care home capacity, staffing, funding, financial viability, and inconsistent support from overstretched local NHS services not adequately resourced for the job, and the press showed fleeting interest.8

“Abandoning” residents

The mainstream media narrative around covid-19 care home deaths became one of cruel bureaucrats, politicians, and managers callously abandoning care home residents to preventable deaths, knowingly sacrificing residents to “protect” acute hospital beds. Allegedly, hospitals had deliberately sent residents back to care homes with no covid-19 tests or even after positive ones.8 New data analysis suggests that discharges from hospitals back to care homes increased year on year during a critical period in March,9 despite claims from the government and NHS Providers that discharge numbers from hospital to care homes had been much lower in March and April than in previous years.1011

Before any instruction from NHS England, emergency legislation, or government cash injections,12 acute hospitals around the country were busy implementing escalation plans to prevent hospitals from being swamped. Part of this was a focus on more ambulatory emergency care, prompt transfer of inpatients back home (or to care homes or community hospitals), and close collaboration with community health services to enhance support and speed.

It’s not politicians, officials, and NHS managers who admit or discharge hospital patients but doctors, working alongside multidisciplinary clinical teams. Many of us clearly were—in good faith, and for understandable reasons in that early pandemic context—sending people to care homes with or without covid-19 testing. We also bear responsibility and shouldn’t seek to deflect all of the blame.

But remember that, in March and early April, even acute hospitals struggled to get covid-19 testing for our own patients or staff, the turnaround time was often days, and we now know that first tests are negative in around one in three cases where people go on to test positive. The links are not clear between testing positive or negative and being infective to others or how long a “safe” period of quarantine is.13 Indeed, someone could test negative, leave hospital, and then test positive days later in a care home. And a care home resident stuck in hospital could contract covid-19 while there, avoidably.

The road not taken

Recent research from the London School of Economics has suggested that not all care home outbreaks have been seeded from hospital transfers, with the staff themselves being vectors, especially agency staff working across multiple settings, and with staff often going between residents’ rooms to give care.14

But let’s just imagine the counterfactual: the road not taken. How would people have reacted if large numbers of acute beds, in a country with one of the lowest (and fullest) per capita bed bases in the Western world,15 had been taken up for weeks by medically stable care home residents, away from their families and familiar staff? And, despite media accounts from the care home sector about struggles to get patients seen or conveyed to hospital by NHS teams, I’ve yet to see robust data on residents who died from covid-19, or other causes, who would have been saved by acute hospital treatment and were denied it.

I believe that some of the now clearly mistaken decisions in local services about care homes were made in good faith, in novel and urgent contexts—and yes, many European countries have experienced similar care home death rates from covid-19. Neither a defensive denial of events in plain sight nor the blame game will help. What matters now is how we might do things differently to protect care home residents if we have a second surge or a new pandemic—something I’ll discuss next week.

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