Discharges into care homes: a complex, nuanced picture

Saffron Cordery profile picture

19 May 2020

Saffron Cordery
Deputy Chief Executive
NHS Providers


The political and media spotlight on care homes during the coronavirus pandemic has once again shown the fundamental importance of the care home sector and the compassion and dedication of care home staff in looking after some of the most vulnerable in our society. But care homes have become an epicentre for the pandemic, lacking sufficient support, and struggling to access testing and sufficient personal protective equipment (PPE). 33% of care homes have reported an outbreak, analysis shows excess mortality rates in care homes are much higher than national data shows, and there are equally tragic reports of deaths of both care and NHS workers.

Given the stakes, it is essential that we swiftly learn lessons internationally and at home from the experience within care homes. However, in some quarters, this has turned into an unhelpful blame game. It has been suggested for example that the crisis in care homes was caused by trusts 'systematically' and 'knowingly' discharging COVID-19 patients into the care sector. This debate needs to be reframed given that, as with many COVID-19 challenges, it is much more complicated when you scratch beneath the surface of the headline.

Long before COVID-19, the social care system was in crisis. Years of under-investment created an unsustainable funding model and fragile provider market. Care staff were already working under huge pressure, with low pay, 122,000 vacancies and high turnover rates. When COVID-19 hit, the disparate nature of the care sector meant that access to PPE, testing and rigorous infection prevention and control (IPC) processes was a challenge. The impacts of COVID-19 on care homes must be examined in this context.

 

33% of care homes have reported an outbreak, analysis shows excess mortality rates in care homes are much higher than national data shows, and there are equally tragic reports of deaths of both care and NHS workers.

   

 

The NHS also entered the pandemic in a weakened position, with growing demand, high vacancy rates and widespread financial constraints. The biggest challenge for the NHS was to avoid being overwhelmed as Northern Italy was, so trusts were instructed by NHS England and Improvement on 17 March to discharge medically fit patients from hospital in preparation for the peak of the pandemic.

In the past week, trusts have come under scrutiny for following this national instruction. However, trust leaders are emphatic that they did not systematically or knowingly discharge COVID-19 patients into care homes. They followed national guidance throughout and worked with local authorities and care providers to agree local discharge approaches that managed the overall balance of risk to individual patients, including the risks of de-conditioning and multiple moves for elderly people in hospital beds.

Trusts leaders recognise that, in the first few days after 17 March, small numbers of asymptomatic COVID-19 patients may have been discharged into care homes, but they quickly became aware of this risk and "within one or two days" had developed new approaches that were based on providing alternative arrangements to isolating patients if care homes were unable to do so safely. Testing capacity was not reliably and consistently available across the country during the period from March to mid-April, nor required for care home discharges until 15 April, but trusts were testing symptomatic care home residents wherever capacity allowed.

 

Trust leaders are emphatic that they did not systematically or knowingly discharge COVID-19 patients into care homes. They followed national guidance throughout and worked with local authorities and care providers to agree local discharge approaches that managed the overall balance of risk to individual patients, including the risks of de-conditioning and multiple moves for elderly people in hospital beds.

   

 

Other factors must be considered in order to understand the spread of infection within care home settings, alongside NHS discharge policy, including national guidance on care home visiting (which was not restricted until 2 April), staff turnover and working patterns (e.g. across multiple homes). Without data on these issues, it is difficult to work out the most likely way in which COVID-19 entered each care home. The latest data referred to by NHS England and Improvement shows a 38% drop in the number of patients discharged into care homes from hospital in February to mid-April compared to January. During this time only 3 in 20 patients discharged from hospital returned to a care home or were admitted for the first time.

From the outset, trusts were acutely aware of the need to protect patients they were discharging to care homes. They built on existing collaborative arrangements and supported homes with PPE via mutual aid schemes, delivered training on IPC and redeployed staff to keep care homes open when staff shortages threatened closure. In one healthcare system in the East Midlands, following discussions across the system, a care home agreed to focus on accepting only COVID-19 positive residents, with support from the local community provider. Another trust redeployed staff from deprioritised services to support care homes with therapeutic, nursing and mental health teams.

Of course we cannot account for every discharge from all 217 trusts, and we recognise there are reports of care homes being pressured to accept discharges which need to be investigated locally. However, in our view any attempts to place blame on the care sector itself or trusts are misleading at a time of unprecedented challenge when health and care colleagues have been pulling together to best support patients.

 

However, in our view any attempts to place blame on the care sector itself or trusts are misleading at a time of unprecedented challenge when health and care colleagues have been pulling together to best support patients.

   

It is clear that a public inquiry will be necessary to determine the causes behind the COVID-19 crisis in care homes.  That inquiry will need to consider the timeliness and effectiveness of decisions taken by the government, including learning from the international community, the impact of the delay in developing testing capacity and sufficient supplies of PPE and the differences in national support, responsibility and coordination for the NHS and the care sector. It must also consider how to properly fund social care and ensure it is fully integrated into local health and care systems.

Until we have the conclusions of any well-evidenced review and public inquiry, we need to recognise this is a complex, nuanced picture. Health and care staff are doing their absolute best in incredibly challenging circumstances with the resources available at the time, so the blame game must stop.

About the author

Saffron Cordery profile picture

Saffron Cordery
Deputy Chief Executive
@Saffron_Policy

Saffron is NHS Providers deputy chief executive, part of the senior management team and sits on our board. She has extensive experience in policy development, influencing and communications and has worked in the healthcare sector since 2007. Before moving into healthcare, Saffron was head of public affairs at the Local Government Association, the voice of local councils in England. Her early career focused on influencing EU legislation and policy development, and she started working life in adult and community education.

She has a degree in Modern Languages from the University in Manchester, for ten years was a board member and then chair of a 16–19 college in Hampshire and is a trustee of GambleAware, a leading charity committed to minimising gambling-related harm. Read more

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