Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Preventing more deaths in care homes in a second pandemic surge

BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2461 (Published 23 June 2020) Cite this as: BMJ 2020;369:m2461

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  1. David Oliver, consultant in geriatrics and internal medicine
  1. Berkshire
  1. Davidoliver372{at}googlemail.com
    Follow David on Twitter: @mancunianmedic

I hope my column last week showed that all of us had a part to play in the high number of deaths from covid-19 in care homes.1

In due course I expect there will be a public inquiry into our handling of the covid-19 pandemic, and endless research and analyses. For now, though, my main concern is what we should do differently if we have a second peak of covid-19 or a pandemic caused by another novel virus.

There are some ways in which we would be better prepared. We now have greater testing capacity in care homes, although it’s a shame it took so long, and some care homes are still reporting difficulties getting their staff and residents tested.2

Homes now seem to have better, though still imperfect, stocks of personal protective equipment.3

The medical and scientific community has a much better understanding of how the virus behaves and presents and of the course of illness in older people, including in the care home population.45 Yet we still don’t know how long people remain infectious to others. Nor do we know the rate of asymptomatic carriage among health and care workers.

We have a better idea of how intensive care and the acute bed base would cope in a second wave, without having to transfer patients into field hospitals.

For me, this first wave brought three main lessons we need to learn to be better prepared in case of a second one.

First is the need to include the care home and home care sectors as equal partners in escalation plans and guidelines, at both local and national levels. Infection control, testing, and transfer policies need to be signed off by all parties, who should be engaged in solutions and whose concerns about their own constraints should be listened to, with a public health overview. The care home sector should not be an afterthought—done unto by the NHS.

Second, there is a need to create some very local capacity in step-down beds, to enable care home residents to be isolated and quarantined. Although the duration of this is still to be agreed, depending on emerging science and testing capability, it would avoid endangering the acute bed base during the pandemic peak and, in turn, patients without covid-19 who also need to access hospital care.

Third, care homes need adequate support from local primary and community health services, including access to palliative care, oxygen, and medications. Such models of enhanced support to care homes are well established, backed by good practice guidance and a clear aim stated in the NHS Long Term Plan’s “ageing well” section.6789 But their use is highly variable. Sadly, they seem to have been put on the back burner, with the focus solely on the GP contract, not those wider supports, and with a lack of clarity over dedicated funding.

And perhaps with care homes getting more public attention than at any point during my career, this will give us the impetus to provide some more meaningful, lasting, and credible solutions to the funding and provision of social care, as was promised by the prime minister in the Queen’s speech at the start of this parliament,10 as well as better alignment and integration with the NHS.

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