Report of the Swedish Corona Commission on care of older people during the pandemic

The Swedish government set up a Commission to evaluate the measures taken to limit the spread of COVID-19, and the effects of the spread, by the government, the relevant managing authorities, the regions and municipalities.

The first interim report has been published on the 15th of December and it looks in particular at care for older people during the pandemic. The full report is here (in Swedish), and an English summary is also available here. Here is a brief summary of the key points.

Key points:

Huge impact on people relying on care:
  • Almost 90% of people who died were aged 70 or older, of these, half were living in long-term care residential facilities and just under 30% were receiving home help services, this is in line with other countries.
The strategy to protect older people failed:
  • Long-standing structural shortcomings led to residential care being unprepared and ill-equipped to handle a pandemic. Staff were left to tackle the crisis by themselves.
  • Measures were late and insufficient, despite early information that older people were particularly vulnerable.
Structural shortcomings in the care sector:
  • Fragmented organisation of the care system across regions (health), municipalities (social care) and central government agencies. There was no overview of preparedness to tackle a pandemic and there were no established communication channels to facilitate operational coordination and collaboration. Lack of integrated patient records identified as a threat to safety.
  • Need for higher staffing levels, greater expertise and better working conditions: employees worked under extreme pressure and risk. The Commission highlights need for improved employment security and staff continuity, relying less on zero-hours contracts, and also need for higher share of medically trained personnel.
  • Inadequate regulatory framework: no legislative backing for use of restrictive measures in crisis circumstances.
  • Lack of municipal access to medical equipment or employment of physicians: this restricted the municipalities’ ability to plan healthcare responses during the crisis. Medical equipment should be available in residential care, for medical interventions and good palliative care.
Late and insufficient measures
  • Late attention to long-term care: protecting the older population was a stated objective from the beginning, but there was no attention to the lack of preparedness and shortcomings in the municipal social care sector until later, as initial focus was on regional healthcare capacity. The government agencies in charge of the response did not have an adequate overview of the care sector.
  • Problems with personal protection equipment (PPE): the absence of clear guidelines and lack of PPE in LTC settings contributed to the spread of the virus. It took unreasonably long to clarify and define the need for PPE in LTC, there were no channels to report needs or organise delivery.
  • Late introduction of testing: A national strategy for testing was not published until 17th April, testing of people discharged to care homes should have taken place, as we as of new admissions.
Visiting restrictions imposed too late and not re-evaluated often enough
  • Ban on visits introduced on 1st April. Although there is no known evidence from Sweden on the effects of the ban on visits, the Commission considers that visits carried a risk and should have been banned earlier. Some providers and municipalities did so. Once ban was introduced, there was no mechanism to assess whether it needed to continue. It should have been made clearer that visits were to be permitted in end of life situations.
Other shortcomings
  • Guidelines regarding access to hospital care increased risk: Low number of referrals to hospital for residential care residents during February-June. In Region Stockholm, triage protocols gave lowest priority to people scoring high on the Clinical Frailty Scale (most care home residents). The Commission warns against using guidelines based on simple categories to determine individual need for care.
  • Lack of physician present and no individual assessments by physicians: analysis of records of care home residents showed many were not individually assessed by a physician or a nurse, and the Commission considers problematic the use of online physician assessments concerning hospital admissions.
Responsibility for the shortcomings
  • The Commission considers that ultimate responsibility rests with the Government.
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