Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Was the prime minister justified in blaming care homes for poor covid-19 practice?

BMJ 2020; 370 doi: (Published 15 July 2020) Cite this as: BMJ 2020;370:m2741
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}
    Follow David on Twitter: @mancunianmedic

On 6 July the UK prime minister, Boris Johnson, told journalists that “too many care homes didn’t really follow procedures” during the covid-19 pandemic, arguably implying that this fuelled the spread of the virus.1

The reaction from the health and social care sector was swift and condemnatory.2 On 7 July the health secretary, Matt Hancock, refused to apologise in the House of Commons and claimed that “the PM was explaining that because asymptomatic transmission was not known about, the correct procedures were therefore not known.” Was there any substance to Johnson’s inflammatory remarks?

The Office for National Statistics (ONS) reported 19 394 covid-19 related deaths of care home residents in England and Wales from 2 March to 12 June—29.3% of all deaths of care home residents in that period.3 And 56% of care homes in England had reported at least one covid-19 case.

Well, in March and April the government and arm’s length organisations actively urged the transfer of patients from hospital to care homes and explicitly said that prior testing for covid-19 was not required.4 The Coronavirus Act5 also gave new permissions for speedier assessment, and additional “emergency coronavirus funds” were made available to help protect acute hospital beds.6

Not until 15 April were government agency guidelines updated to require testing before transfer, once the scale of outbreaks in care homes became apparent. These were the official “correct procedures” from Johnson’s own government. Nobody would argue that practice in an estimated 11 400 care homes run by 5000 providers in England7 could be uniformly perfect. I’ve chatted off the record with senior people from the care home sector who acknowledge that new guidelines and care homes’ ability to follow them have been variable and affected by leadership, training, and staffing. Some homes have been more assertive than others in refusing to take residents from hospital without a negative covid-19 test.8 I’ve also seen data (as yet unpublished) on the high prevalence of asymptomatic infection among residents and staff.

But I’ve seen no credible evidence to back up Johnson’s assertion that care homes weren’t following correct procedures. And care homes were left with a woeful shortage of PPE and no access to testing, largely from poor government policy.9 Their staff and leaders often put their own health on the line, slept on site, and worked long hours for their duty of care to residents. In May some local authorities were reported to have pressured care homes into accepting hospital transfers and threatened to withhold funding or access to equipment.10

Before the pandemic many care homes were struggling to remain in viable business, where maximum fees from local authorities didn’t cover care costs and where “self-funding” residents paid higher rates and effectively cross subsidised the council funded ones.9 It’s no wonder the “uplift money” that came with accepting new residents or transfers from hospitals during peak pandemic proved hard to resist for some. Many local authorities now seem close to bankruptcy—with covid-19 the last straw, further threatening social services.11

The ONS3 found that care homes with high use of agency staff, especially those working across multiple sites, had more covid-19 outbreaks and deaths. Those that didn’t provide sick pay had higher rates still, as staff naturally felt obliged to work when sick rather than be supported to self-isolate. The care home sector isn’t blameless, but the prime minister must realise that its current perilous predicament results partly from serial policy decisions made, over the past decade, by the party he now leads.


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