Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: The story of covid in care homes—neither mystery nor melodrama

BMJ 2021; 373 doi: https://doi.org/10.1136/bmj.n1432 (Published 09 June 2021) Cite this as: BMJ 2021;373:n1432

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  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com
    Follow David on Twitter @mancunianmedic

On 26 May, Dominic Cummings, the prime minister’s former chief adviser, gave oral evidence to the all party select committees on health and science. One of his claims was that England’s health and social care secretary, Matt Hancock, had repeatedly assured him, the prime minister, and the Cabinet that patients in acute hospitals would not be transferred back or admitted to care homes without negative covid tests and that care homes would be protected.12 We now know that many hospital patients in March and April 2020 were discharged without covid testing, or with positive tests, or with care homes not being notified of test results.3

Predictably, Cummings’s testimony was weaponised by the media and by critics of Hancock and the government as evidence of incompetence, cover-up, and dishonesty. Equally predictably, Hancock mounted a bullish defence in parliament the following day, saying that testing capacity had not existed in the early pandemic and that he had led the drive to create capacity for up to 100 000 tests a day.4

This is what can happen when technical, professional issues—such as infection control policy, the value of diagnostic tests, hospital discharge arrangements, and guidance—are reported and framed by political journalists rather than specialists in health and science.5

The reality is more nuanced, and the data and timeline of events are largely in plain sight. The multidisciplinary, multisite Long Term Care (LTC) Covid alliance produced a well evidenced report last year with a timeline of key events around covid.6 The Health Foundation produced detailed reports on the impact of covid on social care, including care homes, in June 20207 and May 2021.8 The parliamentary health and social care committee inquiry, Coronavirus: Lessons Learnt,9 has taken much public evidence over several sessions. The National Audit Office has also discussed this issue in its recent “initial learning” report on the pandemic response.10

We already know that official guidance from Public Health England, NHS England, and the Department of Health and Social Care, published in March and April 2020,1112 actively encouraged rapid discharge of hospital patients to care homes without waiting for tests, until publication of the covid social care action plan on 15 April 202013 after a negative reaction from the care home sector, residents’ families, and some clinicians.

The focus on rapid discharge of patients from acute hospital beds into community facilities or their own homes was justifiable in the context of an early novel pandemic with extremely limited testing capacity (and recent harrowing experiences of overwhelmed hospitals in other countries), if misguided in hindsight. But NHS clinicians, managers, executives, and senior leaders contributed to making these decisions as much as any politicians. Concerns raised by care home and social care leaders and public health experts at the time were over-ridden.

We know that keeping lots of care home residents in scarce beds, waiting for tests we had insufficient access to, with a high first false negative rate and no clear understanding of how long people remained infectious, could have posed other risks to these residents and to other patients in need.14

We know that the care home sector had insufficient access to personal protective equipment or testing for staff and was initially not involved in drawing up plans or policies, and false assumptions were made about its ability to contain outbreaks. The support care homes received from local NHS services ranged from brilliant to patchy and unreliable. And many care home outbreaks were seeded not by hospital discharges but by staff who were infected without knowing it, or were unable to self-isolate, or worked on multiple sites.1516 Hancock and other ministers played down all of this publicly—and, if Cummings is to be believed, privately too.

Distorting the truth is not acceptable in public office. But none of this is news. What matters more are the conditions still facing care homes in terms of funding, staffing, and NHS support; what we learnt and how we changed between the first and second waves; and, most importantly, what mitigations we have in place for the future.

The real story of care homes and covid in the first wave was not so much the melodrama or mystery reported after Cummings’s incendiary evidence as a farce of brazen denial and a tragedy for the care homes and their residents.

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References

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