COVID-19 in care homes: What happened and how should we go forward?

29 May 2020

By Professor Mary Daly FAcSS FBA ( Professor of Sociology and Social Policy, University of Oxford)  

What happened?

While we are still gathering the evidence on the particular vulnerability of care homes to the pandemic, the statistics to date are arresting and disturbing. As of  May 19 2020, there had been nearly 15,000 COVID-19 attributed deaths among care home residents in England and Wales, with estimates suggesting such deaths may account for up to 40% of all COVID-19 deaths.  The mortality rate in care homes in England and Wales is up by 50% (or 23,000 people) in the first four months of 2020 as compared with 2019. Care workers have been twice as likely to die from COVID-19 compared with the general population, and are more likely to die from the virus than health workers. These figures raise serious questions about the adequacy of the response and suggest that in going forward research into the prevailing practices, policies and political priorities is pivotal.

It is vital to uncover the whole story. While this will take time, it does appear that the policy response was inadequate, slow, reactive and too late in key respects. For example, there were few early attempts to prevent or control the spread of infection to care homes so the ‘prevention/protection’ phase was more or less bypassed. Of particular note is the fact that recovering COVID-19 patients could be released from hospital to the ‘community’ without a negative test until mid-April. This opened the door of many care homes to the virus. Another noteworthy aspect of the response was the lack of specific targeting of care homes for testing or PPE or indeed general support measures for staff until relatively late in the day. By mid-April an action plan for adult social care was announced in which care homes were just one of a number of sectors to receive support. But it would be mid-May before a targeted support package and infection control fund in care homes was introduced. This is 10 weeks after the general action plan on the virus (which was announced on March 3).

Why such an inadequate policy response?

Some clear lines of explanation suggest themselves already.

There are good grounds to claim that the systems in place buckled under the pressure. It is difficult to appreciate just how complex our adult social care system is and how diverse are the modes of provision through care homes. For policy and governance purposes, care homes sit within the field of adult social care which is historically, financially and legislatively separated from the NHS. This systemic divide made an integrated response to the virus almost impossible. There are many examples of the channels or supply routes for virus testing and PPE failing for care homes because they could not get access through the far-better resourced, first priority (but still inadequate) NHS channels.

Moreover, care home provision in the UK is largely privatised and marketised, with the vast majority of the homes in the for-profit sector. The state has been removing itself from provision for quite a long time and today no more than 5% of care homes are publicly-run. The fact that there are over 11,000 care homes for older people in England alone, most of them run by sole operators, further complicates the landscape in which a rapid and effective policy response was needed. Moreover, the sector has been subject to  austerity policies which have slashed local authority funding. While the councils made attempts to protect funding for adult social care, the cuts have been passed on in reductions to fees paid by the local authorities, as well as a reduction in the number of people receiving any public help with their social care needs. Care homes have suffered from reduced income, and the workforce has been affected accordingly with problems of recruitment, retention and poor working conditions. A key part of the explanation therefore is that the pandemic hit a complex, poorly organised sector, divided from the NHS and weakened by under-resourcing.

As well as systemic and resource-based elements, the effect of the pandemic on care homes also had cultural causes.

When one examines the government response, one of the striking points is how far down the chain were care homes and the degree to which the NHS was front and centre of the response. This was obviously government strategy. Its main slogan – repeated ubiquitously on all public information from early March to 10th May – ‘Stay Home – Protect the NHS – Save Lives’- gave the NHS top billing (and, moreover, represented it as being at risk). But beyond this, most if not all of the public outreach initiatives came to be framed through an NHS lens, although this occurred through more diverse means than government direction alone. The ‘Clap for Carers’ initiative (which began on March 26 and was widely embraced by the public) was telegraphed in terms of applause for caring within the NHS system. The term ‘carer’ – not a label normally adopted by health service personnel who tend to prefer professional labels – was generally appropriated for care in a health setting (although its meaning did open out over time towards more inclusive terms such as ‘frontline workers’ or ‘key workers’). The original ‘carers’ – those in the formal and informal care sectors – were denied parity and recognition, included as time went on mainly as a kind of afterthought.

Future responses

If the lessons from the pandemic are to be taken seriously, there are certain things we might expect to happen in the near future. For example, we might expect to see a public enquiry into the treatment of care homes. We might also expect to see some specific funds made available to address the trauma and grief of those affected, including staff, residents, families. In the longer term, the failings in the response to the pandemic in care homes can only be addressed by bigger-picture changes in how we fund and organise care itself and how we envisage an appropriate response to the preferences and needs of older people. These and other developments are worth monitoring.

Going forward there is an immediate task for the social sciences in pinpointing and understanding the effects of contributory factors. This is an endeavour to which many disciplines can contribute. The sociologists might examine the extent to which and how the undervaluing of social care generally as well as the widespread perception of care for older and vulnerable people as a burden contributed to the outcomes we see. They might also enquire into how societal attitudes to ageing and age discrimination fed into the treatment of care homes in the pandemic. The policy experts might pose searching questions about the long policy chain to care homes and why the UK lacks a recognisable field of ‘long-term care’ policy, especially in the context of its ageing society. They might also examine why so much of the policy attention in this country focuses on the efficiency of care markets, and why the system of governance functions so poorly. Political scientists might research why the policy landscape on adult social care is to all intents and purposes frozen in this country and why the interests representing social care have been relatively ineffectual in the public sphere as the pandemic unfolded, in contrast to those in the health sector. Cultural studies experts might turn their attention not just to why the NHS occupies such a treasured place in the national self-construction but how this impacts national attitudes to social care. Why is one constructed as a source of pride and the other as a source of shame?

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Professor Mary Daly FAcSS FBA, is Professor of Sociology and Social Policy at the University of Oxford and a Governing Body Fellow at Green Templeton College. Her specialist research interests include poverty, children’s rights, gender equality, family and labour market policies. Much of her work is comparative, in a European and international context. She is a member of a number of European networks and boards on topics related to the welfare state, employment, family, children and gender inequality. She has advised many national and international bodies and institutions.

The perspectives expressed in these commentary pieces represent the independent views of the authors, and as such they do not represent the views of the Academy or its Campaign for Social Science.

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This article was originally commissioned and published by the Campaign for Social Science as part of its Covid-19 programme.