By Malcolm Kendrick, doctor and author who works as a GP in the National Health Service in England. His blog can be read here and his book, ‘Doctoring Data – How to Sort Out Medical Advice from Medical Nonsense,’ is available here.
As a GP, I regularly visit care homes. At one I go to, they recently lost eight residents in a week, probably from coronavirus. But there’s no testing, the staff have no protective equipment, and ministers have no strategy.
When Covid struck, many things were not known, and could not possibly have been predicted. The transmission rate, the case fatality rate, the best way to treat those infected.
However, it was very clear, very early on, that Covid was killing the elderly in far greater numbers than anyone else. In Italy, the early figures released revealed that the average age of death was seventy-nine. The figures were slightly higher in Germany, and around eighty years old in pretty much every other country.
Equally, it was known that, amongst the elderly who were dying, almost all of them had other serious medical conditions. Heart disease, high blood pressure, diabetes, chronic pulmonary disease and suchlike. This is often known in my line of work as “multimorbidity.”
In a world of uncertainty, one thing stood out. Which is that the unwell elderly were the ones who were most likely to die. Equally, they were the ones most likely to end up in hospital, potentially overwhelming the health services. As happened in Italy and Spain.
Ergo, you would think that someone, somewhere in the UK government, would have asked the obvious questions. Where do we have the greatest concentrations of elderly, frail, people with multimorbidity? Could it possibly be that they are being looked after in care homes around the country?
Nursing homes, residential homes, care homes. They are all pretty much the same thing nowadays. Nursing homes tend to look after those with greater health needs, and they must have registered nurses looking after patients, but the distinctions have become blurred.
Many care homes are also specialised in looking after the elderly with dementia. In the UK, they are called EMI units [elderly mentally infirm]. These represent a particular problem in that residents tend to wander about from room to room.
So, in care homes we had potentially the perfect storm for the pandemic. They are full of elderly and infirm and highly vulnerable people. Environments where it is often impossible to isolate residents, and staff who have never been adequately trained in isolation measures. Equally, whilst relatives cannot visit hospitals, care homes have been continuing to allow them in.
It is not as if the warning signs were not there, flashing red.
What was the government’s strategy for dealing with nursing homes? It has been, up until the last couple of days, to make things even worse. The instructions from the Department of Health have been to send patients diagnosed with Covid out of hospital, and back into care homes, with instructions to “barrier nurse” them, a term for a set of stringent infection-control techniques. Care homes have been informed that they cannot refuse to take the residents back.
All of which means that the staff end up attempting to barrier nurse Covid positive patients with flimsy surgical masks, no eye protection, no gowns and gloves that, in my case, disintegrate rapidly and are almost completely useless. Until very recently, nursing home staff, in many homes, were told not to wear masks, and this was true even when there were Covid positive patients in the home.
The focus, the entire focus, has been to clear patients out of hospitals, waiting for the deluge of patients. This has been so effective that, in my area of Macclesfield in Cheshire, the local hospitals have never been so empty.
There are wards with no patients in them. The shiny new Nightingale hospital in London, with four thousand beds, apparently had just nineteen patients in it last weekend. Yet still the pressure still comes down: get patients out of hospital and back into care homes.
At the same time, all the effective personal protective equipment (PPE) has been directed to hospitals and hospital wards. Care homes have been almost unable to access anything. I scavenge what I can before I visit. I keep being told that things have improved. By those who haven’t seen a patient – or the inside of a care home – for years.
I have also watched patients go down very rapidly and die. Covid is a strange disease that kills people in a way that I have never witnessed before. In some cases, very quickly. I have tried to suggest that hospitals are the best place to look after potentially infectious people, not care homes. No-one has been interested.
Now, of course, the disaster is unfolding. The entirely predictable disaster. Here, from The Guardian:
‘Care home leaders have accused the government of vastly underestimating the deaths of elderly people from coronavirus, as they warned the disease may be circulating in more than 50% of nursing homes and mortality is significantly higher than official figures.
Operators of several large care providers accused the government of not paying enough attention to the tragedy unfolding in residential settings across England, as figures from three of the largest chains show 620 deaths from Covid-19 in recent weeks.’
In one care home where I visit, they recently had eight deaths in seven days. Were these Covid deaths? Who knows for sure. No-one was tested. No-one is tested. The staff are not tested. I have patients who have died quickly. What do I put on the death certificate? Covid? Well I cannot, not really, because I have no idea if they had Covid or not.
It seems clear that many, many, Covid deaths in care homes will not even be registered as Covid deaths, so the figures are almost certainly worse than are being reported.
I think we all recognise that the Covid pandemic has hit the country with great force, and that the Government has had to react at great speed. You can agree or disagree with some of the actions. However, one thing that stands out is that complete and utter abject failure to grasp the impact of Covid on care homes.
The actions taken, so far, have made the problem far, far, worse. All the thinking and resources have been directed to the NHS. Meanwhile, the residents and the staff of nursing homes have been, effectively, thrown in front of a bus. On Thursdays, while others have been clapping the NHS, I have been clapping for the unsung heroes of this epidemic. The care home staff.