Responses to the International Living Report Questions on COVID-19 and Long-Term care:
This is the section for England from a “living report” that aims to provide an overview of how Long-Term Care systems around the world have been affected by the COVID-19 pandemic, how they have responded and what lessons are being learnt. This report does not seek to provide detailed or comprehensive information for each country, but instead aims to summarize key reports and articles and point the reader towards those sources. It builds largely on the reports previously published in this website. It is being developed collaboratively, by answering a list of questions for as many countries as possible.
This page shows the answers currently available for England and is automatically updated as new information is added.
This report has been initially developed by the team working on the Social Care COVID Recovery and Resilience project and questions will be added to and validated by LTCCovid contributors who are experts on Long-Term Care in their respective countries. This study is funded by the National Institute for Health Research (NIHR) Policy Research Programme (NIHR202333). The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Please cite as:
Comas-Herrera A., Marczak J., Byrd W., Lorenz-Dant K., (editors) and LTCcovid contributors. International living report on COVID-19 and Long-Term Care users and providers: context, impacts, measures and lessons learnt. LTCcovid, Care Policy and Evaluation Centre, London School of Economics and Political Science. Available at: https://ltccovid.org/country-questions/
PART 1 – Long-Term Care System characteristics and preparedness
- 1.01. Population size and ageing contextBy mid-2020 the population in England was estimated to be 56,550,000, representing 84% of the total population of the United Kingdom. The median population age in England was 40.2 years. The share of the population aged 65 years and over was 18.5% and the share aged 85 and over was 2.5%. (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationestimates/bulletins/annualmidyearpopulationestimates/mid2020#population-change-for-uk-countries).
- 1.02. Brief description of the Long-Term Care system
The majority of long-term care in England is provided by unpaid carers. Formal long-term care in England is provided by a complex system involving organisations in charge of health, social care, housing and other services. There is an important distinction between means-tested social care (non-medical services aimed at supporting people with LTC needs with their daily living activities) and health care services, which are free at the point of use and funded from general taxation.
Formal care services include home-based care services, personal assistants, residential/institutional care, day care and professional services such as social work, occupational therapy and aids and adaptations. Most publicly funded services are commissioned at local level, but, as a large share of the population who use long-term care is not covered by the public system, a large share of care is purchased directly from private providers.
There is strong consensus on the urgent need to reform the social care system in England.
For further reading:
- 1.03. Long-term care financing arrangements and coverage
In 2018, LTC expenditure in the United Kingdom was estimated to represent 1.8% of Gross Domestic Product (source: https://stats.oecd.org/Index.aspx?QueryId=30140).
Local authorities are funded largely through a combination of a grant from central government and local revenue-raising mechanisms, including council tax for example. Social care funding is not ring-fenced, which means that local authorities can decide how much of their budget they allocate to care. Unlike the NHS, where healthcare is free to those using it, access to social care is determined by both need and means. A restrictive means test, which has not been adjusted since 2010, means that people with property (including housing), savings or income in excess of £23,250 must meet the entirety of their care costs alone. Those with means below the threshold of £23,250 may be eligible for part or full state funding for their care but they must also be deemed to have sufficiently severe care needs.
The distinction between ‘health’ and ‘care’ creates further inequity. A person deemed to have health needs may be able to access social care via the NHS’s continuing healthcare programme (although subject to restrictive eligibility criteria and long waiting times), but someone with personal care needs (e.g. arising from dementia) and no medical requirements is subject to the means test (source: https://www.nuffieldtrust.org.uk/news-item/other-types-of-support-how-do-the-countries-compare#support-for-health-needs).
In 2018/19, total expenditure on social care by councils amounted to £22.2 billion. There are few estimates of private spending on care, however the National Audit Office has estimated the size of the self-funder market (i.e. those who pay for their care) at £10.9 billion in 2016/17 (source: https://www.kingsfund.org.uk/publications/social-care-360/expenditure).
During the last decade, funding to councils has been cut by almost 50% (source: https://www.nao.org.uk/wp-content/uploads/2018/07/Adult-social-care-at-a-glance.pdf), which has put pressure on councils to spend less on care either through reducing the rates they pay providers or by reducing the number of people they fund. Because local authorities have a responsibility to revenue locally to subsidise the grant they receive from national government, those local authorities in more affluent areas are able to raise more (source: https://www.ifs.org.uk/uploads/publications/bns/BN227appA.pdf). The result is wide variation in the eligibility for care between local areas, despite the intention of the Care Act (2014) being to standardise eligibility.
- 1.04. Long-term care system governance
The Department of Health and Social Care has overall policy responsibility for adult long-term care policy in England. The assessment of care needs, and the commissioning and organisation of care is the responsibility of 152 local authorities, a small minority of which also run and deliver some care services. Government financial support for local authorities, including their social care responsibilities, is channelled through the Ministry of Housing, Communities and Local Government. Although there are initiatives at local and regional levels which aim to integrate health and long-term care services (with varying degrees of success), they remain two separate systems.
- 1.05. Quality and regulation in Long-term care
The Care Quality Commission (CQC) is an executive non-departmental public body of the Department of Health and Social Care and serves as the independent regulator for both health and long-term care (source: Care Quality Commission (cqc.org.uk).
- 1.06. Approach to care provision, including sector of ownership
Care is provided by approximately 9,000 home care providers and over 15,000 care home providers. Around 78% of all adult care services are privately owned and run (source: https://www.skillsforcare.org.uk/Documents/About/sfcd/Economic-value-of-the-adult-social-care-sector-England.pdf). The Care Act 2014 places a duty on local authorities to ensure that there is diversity and quality in the market of care providers. However, due to the downward pressure on fees stemming from cuts to local authority budgets, many providers find that the fees paid by local authorities fall short of covering the full costs of providing care. People who fund their own care are being charged on average 41% more than local authority funded residents because of this shortfall (source: https://assets.publishing.service.gov.uk/media/5a1fdf30e5274a750b82533a/care-homes-market-study-final-report.pdf). It is increasingly common for care providers to go out of business, struggle to stay in business or hand back contracts to local authorities. A survey in 2019 found that some 75% of councils reported that these organisations had either closed or handed back contracts in the last six months of 2020, creating enormous disruption and discontinuity for those receiving care (source: https://www.adass.org.uk/media/7295/adass-budget-survey-report-2019_final.pdf). Because of market fragility, the government has introduced market oversight and a failure regime covering financial as well as quality failure (source: https://www.cqc.org.uk/guidance-providers/market-oversight-corporate-providers/market-oversight-adult-social-care).
- 1.08. Information and monitoring systems
There is no national minimum dataset for care homes, or social care in England (source: UK Report).During the pandemic, the limited existing data was supplemented by data collections from several bodies (the NHS, providers themselves, the death registration system, Public Health England, and the regulator, CQC). Those working in the sector report that this has led to repeated collection of similar data, by multiple stakeholders. This reflects the lack of data and technology infrastructure in the social care sector, which by comparison with the health care sector in England and Wales, has received little investment.
The COVID-19 crisis has stimulated some technological innovation in care homes; for example, the NHS has expanded the use of encrypted NHS email to care home staff, developed a web portal for Personal Protection Equipment (PPE) emergency procurement, and has piloted ‘remote’ social care interventions. Some care homes and General Practices (GP) have also used tablets and video calling to allow GP visits and to communicate with families. However, this is in the context of fundamental issues with capacity of the care home sector to engage in these initiatives due to a lack of infrastructure (e.g. broadband), or low usage of digital technology among home care staff.
At a provider and individual level, data and information sharing are limited. There have been several successful partnerships between the health and local authority sector across England to link social care data collected by councils with health care data. However, this only covers people whose social care provision is provided by local authorities, not those who pay themselves. There are no national datasets on social care utilisation or individual expenditure and the complex and fragmented nature of the provider market makes data collection difficult. The development of the Capacity Tracker (source: About Capacity Tracker – NECS (necsu.nhs.uk) for care homes, mandated during Covid-19, is a welcome addition with potential to provide market intelligence, although there are concerns about the accuracy of data entered, with implications for planning and prioritisation in central government (source: Covid story_v5.docx (laingbuisson.com). It remains impossible to obtain an accurate estimate of the number of self-funders or total social care spend across all care settings (source: Adult social care statistics: the potential for change | The Nuffield Trust).
- 1.11. Workforce conditions: pay, employment conditions, qualification levels, shortages
There is no national workforce strategy for the adult social care workforce – the last strategy was published by government over a decade ago in 2009 (source: https://webarchive.nationalarchives.gov.uk/20130105063710/http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_098481).
The number of vacant posts in the English social care sector has climbed steadily since 2012/13, reaching 122,000 or 8% of the total workforce in 2019 (source: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-size-and-structure-of-the-adult-social-care-sector-and-workforce-in-England.aspx), with providers having difficulty recruiting and retaining workers, particularly to the roles of care worker, registered manager and nurse (source: https://publications.parliament.uk/pa/cm201719/cmselect/cmpubacc/690/690.pdf). Data indicate that the sector also suffers from high staff turnover, poor working conditions, and 24% of the workforce are on zero-hours contracts. Pay is low and there are few opportunities for training and progression. The adult social care workforce is reliant on migrant labour. It was reported that in total, an estimated 98,710 migrant workers joined the formal care workforce between 2009 and 2019, with 9% from EU and 11% from non-EU countries. In London, more than two in five care workers are from abroad (source: https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/documents/Regional-reports/Regional-report-London.pdf). Care workers have not been recognised as eligible for the ‘skilled worker’ route, in the forthcoming points-based immigration system, due to be implemented on 1 January, 2021 (source: https://www.gov.uk/government/publications/uk-points-based-immigration-system-further-details-statement).
PART 2 – Impacts of the COVID-19 pandemic on people who use and provide Long Term Care
- 2.02. Deaths attributed to Covid-19 among people who use and provide Long-Term Care
The Office for National Statistics provide weekly updates of deaths registered in England, which include any death where COVID-19 was mentioned (by a doctor) on death certificates.
Between December 28, 2019, and November 6, 2020, an estimated 15,659 people died linked to COVID-19 in care homes (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales).
As of March 12, 2021, there have been 127,911 COVID-19 related deaths, with 39,196 of these occurring in care homes (23%) (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales). In terms of deaths of care home residents in England, that is, those care home residents who died from COVID-19 but did not necessarily die in a care home, the Office for National Statistics publish data on weekly deaths of care home residents that are registered in England and Wales. As of March 12, 2021, there have been 41,107 COVID-19 related deaths of care home residents in England and Wales. Subtracting the total number of care home resident deaths in Wales (1,911 deaths) gives a total of 39,196 care home resident deaths in England up until March 12, 20201. Therefore, care home residents accounted for 31% of all COVID-19 related deaths in England. There are 425,408 care home residents in England. Therefore, the number of COVID-19 related deaths of care home residents represents 9.21% of this population.
There is relatively little data on the impact of COVID-19 on people who use long-term care and reside in private households. Using data from the Care Quality Commission, The Health Foundation estimated that, between March 23 and June 19, 2020, there were an additional 4,500 deaths among people using domiciliary care from providers registered with the Care Quality Commission, compared to the previous three years during the same period (an increase of 225%). The deaths of 819 service users had been notified and published as involving COVID-19 during this period.
The Care Quality Commission published a one-off analysis of 386 death notifications of adults with intellectual disabilities using community-based social care or living in residential care from April 10 to May 15, 2020, compared to 165 death notifications for the same period in 2019. Of the 386 deaths in 2020, 206 were confirmed/suspected COVID-19 deaths and 180 were deaths notified as not COVID-19 related. An analysis of 163 people with learning disabilities who died with COVID-19 reported that 35% of these people were living in residential care, a further 19% were living in nursing care, 25% were living in supported living accommodation, and 18% were living on their own or with their family.
Half (49.5%) of all COVID-19 related deaths in care homes in England and Wales between March and June 2020, were in people living with dementia (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/deathsinvolvingcovid19inthecaresectorenglandandwales/deathsoccurringupto12june2020andregisteredupto20june2020provisional?WT.mc_id=f5e0eb1233c5d2a1a4a1b591e46fecbd&hootPostID=1376c0e546f27d0e33d8ce1e242a810f).
The largest number of excess deaths (compared to the last five years during the same period) between March 20 and October 30, 2020, happened in private homes (25,634, of which only 2,571, 10%, were registered as COVID-19), followed by deaths in care homes (22,948, of which 15,415, 60%, were registered as COVID-19). In contrast, there were 2,724 fewer deaths than expected in hospices during that period. These figures do not include all deaths of care home residents, as some will have died in hospital (Source: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregisteredweeklyinenglandandwalesprovisional/latest).
In July 2021, the Care Quality Commission published care home level data on deaths notifications involving COVID-19 for the period from April 10, 2020, to March 31, 2021. In total, the Care Quality Commission had been notified of 39,017 deaths in that period that took place in 6,765 care homes.
- 2.04. Impacts of the pandemic on access to health and social care services (for people who use Long-term Care)
Carers have reported delays in health treatment for the person they care for (57%) and for themselves (38%). More than half of carers (65%) in a Carers UK survey have reported to have postponed attending health care services for their own health needs. Reduced access to health care and social services for the person they support was also reported by carers of people with dementia (90% of 795 respondents) (Source: https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf).
Many community–based care services, such as day care, have been interrupted as a result of the COVID-19 pandemic. Guidance on safe delivery of day care has been published by the Social Care Excellence Institute on the July 10, 2020.
It is likely that there have been reductions in the use of domiciliary care services, such as home care, as a result of people fearing contagion through contact with staff, and as a result of staff shortages due to their own need to self-isolate or shield. Lack of access to PPE and testing for home care providers may have exacerbated this problem. There is no data yet on the extent to which services have been reduced or the degree to which this has affected the people who rely on those services and their family and other unpaid carers, although a national survey by the Association of Directors of Adult Services reported substantial increases in social care need arising from the unavailability of services, hospital discharge, carer breakdown, and concerns about abuse and safeguarding.
- 2.05. Impacts of the pandemic and measures adopted on the health and wellbeing of people who use and provide Long-Term Care
During the early part of the pandemic there were reports of substantial increases in the prescription of anti-psychotics to people with dementia during the COVID-19 pandemic, some of this may have been due to increased need linked to delirium management or palliative care, but it is also likely to be attributable to worsened agitation and distress linked to COVID-19 restrictions (such as people in care homes being confined to their bedrooms, or not able to receive family visits).
- 2.05. Impacts of the pandemic and measures adopted on the health and wellbeing of people who use and provide Long-Term Care
During the early part of the pandemic it was reported that there was evidence of substantial increases in the prescription of anti-psychotics to people with dementia during the COVID-19 pandemic, some of this may have been due to increased need linked to delirium management or palliative care, but it is also likely to be attributable to worsened agitation and distress linked to COVID-19 restrictions (such as people in care homes being confined to their bedrooms, or not able to receive family visits).
People living in care homes
Guidance issued by the government on April 2, 2020, said that care homes should advise family and friends not to visit except in exceptional circumstances. There is concern and, increasingly, reported international evidence that some of the measures taken to reduce the risk of COVID-19 infections in care homes, such as closing care homes to visitors (including family members), reduction in social interactions and activities, and needing to isolate have had negative impacts on the wellbeing and mental health of people living in care homes. There are multiple reports warning about the alarming rate of deterioration that people with dementia are experiencing under these isolating conditions and being detached from their families. For instance, a survey conducted by the charity Alzheimer’s Society found that 79% of care homes surveyed reported that the lack of social contact is causing a deterioration in the health and wellbeing of their residents with dementia. A survey of care homes from across England found that by late May and early June, 2020, 85% of managers had detected low mood among residents.
People living in the community who use long-term care
There is emerging evidence that reduced use of social support services has had detrimental effects on the quality of life of people affected by dementia and older adults (Sources: https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; https://pubmed.ncbi.nlm.nih.gov/32946619/).
People who are employed to work in social care
A survey of 296 frontline care workers that took place during July and August 2020, found that nearly half of the respondents (47%) indicated that their general-health had worsened since the onset of COVID-19 and 60% indicated that the amount of time their jobs made them feel depressed, gloomy, or miserable had increased since the start of the pandemic. Additionally, 81% reported an increase in the amount of time that their jobs made them feel tense, uneasy, or worried. A significant minority of 23% indicated their job satisfaction had increased, whereas 42% said that they had become a little or a lot less satisfied with their job since COVID-19. In another survey of 43 care home managers in England, 75% of managers reported that they were concerned for the morale, mental health, and wellbeing of their staff. In addition, data reported by Skills for Care indicates that the percentage of days lost to staff sickness have increased by 180% (from 2.7% before the pandemic, to 7.5% between March and August 2020).
Unpaid or informal carers
Many carers have expressed the experience of stress and a negative impact on their physical and mental health (Sources: https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/morepeoplehavebeenhelpingothersoutsidetheirhouseholdthroughthecoronaviruscovid19lockdown/2020-07-09; https://www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf; https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://onlinelibrary.wiley.com/doi/10.1111/jar.12811). Carers UK reported that the negative impact on the mental health of carers was greater among carers experiencing financial difficulties. Research found that variations in hours of support were associated with higher levels of anxiety and lower levels of well-being.
- 2.06. Other impacts of the pandemic on people who use and provide Long-Term Care
People who are employed to work in social care
A survey of 296 frontline care workers that took place during July and August 2020, found that 81% indicated an increase in their workload since the onset of COVID-19 and 56% reported an increase in their working hours. Additionally, this found that 18% had to self-isolate, but nearly a fifth of those who needed to self-isolate did not receive any pay. The survey also found that 22% of care workers thought they had not received adequate COVID-19 training or clear guidance, and 16% had not had the necessary PPE to do their job safely. In another survey of 43 care home managers in England, staff had needed to isolate in 72% of care homes. Additionally, 43% of managers reported staffing shortages, with 1 in 3 having to use agency staff, who accounted for between 2 and 37% of their workforce. Providers generally reported receiving little support with surge staffing.
Unpaid or informal carers
Evidence suggests that, since the beginning of the COVID-19 pandemic, a substantial number of people have taken on new care responsibilities
Several reports on unpaid carers have shown that there has been an increase in unpaid carers, many of those who have cared prior to the pandemic have increased their care commitment, largely due to reduced availability of services (Sources: https://ltccovid.org/wp-content/uploads/2021/01/Lorenz_Comas_COVID_impact_unpaidcarers_preprint.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_April20_pages_web_final.pdf; https://www.carersuk.org/images/CarersWeek2020/CW_2020_Research_Report_WEB.pdf; https://onlinelibrary.wiley.com/doi/full/10.1002/gps.5434; https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01719-0; https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf).
A Carers Week and an Office for National Statistics report show that the number of people providing unpaid care has increased substantially since the COVID-19 related lockdown measures were put in place in March 2020. The Office for National Statistics report states that 48% of people in the UK cared for someone outside their own household in April 2020. The Carers Week report estimates that 4.5 million people in the UK have become unpaid carers during the COVID-19 outbreak in the UK. The reports show that people who have taken on new care responsibilities continue to be more likely to be female, although there was a high proportion of men taking on new care responsibilities. Carers who have taken on care responsibilities since the onset of the COVID-19 pandemic were slightly younger (45-54 years) compared to the groups that are usually more like to provide care (aged 55-64). The most frequently reported reasons for an increase in care responsibility were increased care needs and the reduction or suspension of local services. The Carers Week report found that new carers were more likely to be working and to have children (under 18 years).
The amount care provided by family carers has increased
Carers UK have reported that care responsibilities have increased for most carers, with the average time spent caring increasing by 10 hours to 65 hours of unpaid care per week. However, a small proportion of carers have provided less care. An increase in care responsibility and time spent caring was reported among most unpaid carers of people with dementia (73%) (Source: https://www.alzheimers.org.uk/sites/default/files/2020-09/Worst-hit-Dementia-during-coronavirus-report.pdf). Many carers attributed the increase in time spent caring to the reduced availability of services. This proportion was particularly high among Black, Asian and Minority Ethnic (BAME) carers (Source: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf).
Carers express concerns
A survey by Carers UK showed that a large proportion of unpaid carers are concerned about what would happen to the care recipient if the unpaid carer became unable to provide care (87%). A second concern expressed was the risk of infection due to domiciliary carers entering people’s homes. Carers of people with dementia also reported that people with dementia had difficulty following the distancing rules and to understand why their routines had been disrupted (Source: https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292).
Carers experience an impact on their finances
There is evidence of a negative impact on carers finances, with some incurring increased costs (food, bills, equipment) and a reduced ability to work or loss of employment (Sources: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_April20_pages_web_final.pdf; https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf). While some carers highlighted that working remotely provided them with greater flexibility to manage care and work, others experienced greater challenges. Research on unpaid carers caring for someone outside their household found that carers with paid jobs worked fewer hours than other people in employment, and that female carers worked fewer hours than male carers. Financial pressure on carers was also illustrated through foodbank use, with 106,450 carers (1.76% of carers) reporting that their household had to rely on foodbanks in the past month. Foodbank use was higher among female and among young carers (aged 17-30). The research also showed that in the households of 228,625 unpaid carers, someone had gone hungry in the week prior to the survey. Again, this was higher among females and young carers (aged 17-30).
People with intellectual disabilities and autistic people
Relatively little systematic information is available concerning the impact of COVID-19 on the lives of people with intellectual disabilities and autistic people in England, although there is a consistent picture from blogs run by self-advocacy and other organisations in England (Sources: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/925820/covid-and-people-with-learning-disabilities-or-autism-easy-read_v2b.pdf; https://www.learningdisabilityengland.org.uk/what-we-do/keeping-informed-and-in-touch-during-coronavirus/connecting-people-including-webinars/) and surveys of people with intellectual disabilities in Scotland (Sources: https://inclusionscotland.org/wp-content/uploads/2020/04/Initial-Findings-Report-.pdf; https://www.scld.org.uk/wp-content/uploads/2020/06/SCLD-Coronavirus-Report-FINAL.pdf) and Wales (Sources: https://allwalespeople1st.co.uk/wp-content/uploads/2020/05/The-Effect-of-the-Coronavirus-Pandemic-on-People-with-Learning-Disabilities-Across-WalesPhaseOneFinalDraft.pdf; https://allwalespeople1st.co.uk/wp-content/uploads/2020/08/AMBER-The-Effect-of-the-Coronavirus-Pandemic-on-People-with-Learning-Disabilities-Across-Wales.pdf).
Care home providers
There are concerns about the viability of some care home providers, due to lower occupancy rates (as a result of a high number of deaths and people putting off entering care homes), and higher costs linked to additional staffing and PPE expenditure. Analysis by the Care Quality Commission published in July 2020 shows that there has been a substantial reduction in admissions to care homes during the pandemic, although the rates vary significantly. Admissions funded by local authorities for the week ending June 7, 2020, were on average of 72% (range 43 to 113%) of the number received in the same period in 2019. In contrast, self-funded admissions, were on average at 35% of the 2019 levels (25% to 51%). One source reported that the occupancy of care home beds dropped approximately 13% over the course of the pandemic.
Data from a survey by the Care Quality Commission showed that, as of May 2 to 8, 2020, around a fifth of agencies were caring for at least one person with suspected or confirmed COVID-19. Providers also reported that access to PPE was a big concern, with many instances of wrong or poor quality items being delivered. While homecare services were experiencing lower levels of activity (homecare hours were at 94% of pre-pandemic levels), Local Authorities continued to pay for planned hours, which helped to protect the providers they commission from, from the decrease in activity (Source: https://www.cqc.org.uk/sites/default/files/20200715%20COVID%20IV%20Insight%20number%203%20slides%20final.pdf).
- 2.06. Other impacts of the pandemic on people who use and provide Long-Term Care
A report on unpaid carers has shown that there has been an increase in unpaid carers, many of those who have cared prior to the pandemic have increased their care commitment, largely due to reduced availability of services. Many unpaid carers experienced worse physical and mental health outcomes and some experienced financial implications.
PART 3 – Long-Term Care system characteristics and preparedness that may have affected the response to the pandemic
- 3.02. Governance of the Long-Term Care sector's pandemic response
Guidance on Infection Prevention and Control for care homes was updated numerous times during the pandemic. Some of the relevant guidance was issued in policy documents from the Department of Health and Social Care, and some from Public Health England. Initial guidance on February 25, 2020, advised that it was unlikely that people receiving care would be infected (at the time there had been no known transmission within the UK). It was not until April that the guidance documents in England took into account the possibility of pre-symptomatic or asymptomatic transmission both with regards to testing and isolation policies.
- 3.02.01. National or equivalent Covid-19 Long-Term Care care taskforce
On June 8, 2020, the Government announced the creation of a social care sector COVID-19 taskforce in order to ensure concerted action to implement key measures taken to date (Source: https://www.gov.uk/government/groups/social-care-sector-covid-19-support-taskforce). In particular, the taskforce was intended to support the delivery of the Government’s social care action plan, published on April 15, 2020 (Source: https://www.gov.uk/government/news/national-action-plan-to-further-support-adult-social-care-sector), and its home care support package (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes/coronavirus-covid-19-care-home-support-package). The taskforce, which included representatives from across government and the care sector, was intended to ‘support the national campaign to end transmission in the community, and it will also consider the impact of COVID-19 on the sector over the next year and advise on a plan to support it through this period’. The Taskforce published its report in late September 2020, identifying a total of 52 recommendations across a range of domains including PPE, testing, workforce, and controlling infection in different settings. The learning disabilities and autistic people advisory group to this taskforce published 5 key recommendations, which the co-chairs of the advisory group have stated were not reflected in the taskforce report as a whole. These were: accessible guidance and communications, restoring and maintaining vital support services, expanding PPE and testing, tackling isolation and loneliness, and seeking and supporting people who may be in crisis.
- 3.02.02. Measures to improve coordination between Health and Social Care in response to the pandemic
In the absence of rapid and adequate support to the domiciliary care sectors, many providers have turned to local initiatives to continue to deliver care in a safe way, for instance through the use of remote monitoring technologies (Source: https://www.carecity.london/your-blog/221-expert-care-in-covid-19). Providers have furthermore reported improved relationships with the healthcare sector, with a more collaborative approach to supporting vulnerable individuals over the course of the pandemic.
- 3.02.03. Measures to support, facilitate and compensate for disruptions to access to care
During March and April 2020, there was a substantial reduction in hospital admissions among care home residents. Elective admissions reduced to 58% of the 5-year historical average and emergency admissions to 85% of the 5-year historical average. By reducing admissions, care home and NHS teams may have reduced the risk of transmission, but there may have also been an increase in unmet health needs (Source: https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-impact-on-social-care-users-and-staff-in-england-so-far).
To facilitate access to crucial medicines, on April 23, 2020, the Department of Health and Social Care published new standard operating procedures for the use of medicine in care homes and hospice settings in England. The scheme allowed care homes and hospices to re-use medicine that was issued for one resident for another under specific circumstances and only in crisis situations. The guidance document contains information on the specific circumstances in which medicines labelled for one person (who no longer needs them) can be used for another person. The usually strict regulations around re-using or recycling medication were relaxed as there were ‘increasing concerns about the pressure that could be placed on the medicines supply chain during the peak of the COVID-19 pandemic’.
From May 15, 2020, the NHS was expected to ensure that care homes were able to receive clinical support from primary care and community health services.
- 3.04. Financial measures to support users and providers of Long-Term Care
The action plan for social care, published on April 15 2020, confirmed the announcement in March of £2.9 billion of funding ‘to strengthen care for the vulnerable’. Of the £2.9 billion, £1.3 billion was earmarked for collaborative efforts between the NHS and local authorities, particularly to fund additional support following hospital discharge, and £1.6 billion of the funding was allocated to support local government with the provision of services, including adult social care. The Action Plan outlines that local authorities are expected to use the additional funding to ‘protect providers’ cash flow, monitor ongoing cost of care delivery, and ‘adjust fees to meet new costs’. It is anticipated that this funding covers the cost for additional personal protective equipment (PPE) required (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). Furthermore, the government suggests that the additional money provided could also be used for backfilling shifts as well as to maintain income for workers unable to work due to physical distancing measures as far as possible. This is intended to financially support workers who may have to stop working temporarily because they are unwell or self-isolating. Furthermore, the plan made a plea for donations to support social care workers who may experience financial difficulties, similar to the donations that NHS charities have received (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). A survey examining funding access found that only 30% of care home managers reported receiving a financial uplift at the time, with 73% stating that they needed more funding.
On May 15, 2020, a £600 million Infection Control Fund was introduced as part of a wider package of support for care homes to help providers reduce the rate of transmission in and between care homes and support wider workforce resilience (Source: https://www.gov.uk/government/news/care-home-support-package-backed-by-600-million-to-help-reduce-coronavirus-infections). The funding is being paid in 2 tranches. The first was paid to local authorities on May 22. The second tranche was paid in early July (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund/about-the-adult-social-care-infection-control-fund). This money has been allocated to Local Authorities and is in addition to the funding already provided to support the Adult Social Care sector during the COVID-19 pandemic. Local authorities are expected to pass 75% of the initial funding directly to care homes in their area for use on infection control measures, including to care homes with whom the local authority does not have existing contracts. The second payment will be contingent on the first being used for infection control. The remaining 25% must also be used for infection control measures, but local authorities are able to allocate this based on need (Source: https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/885214/14_May_2020_-_MSC_letter_-_support_for_care_homes_1.pdf).
Local authority directors responsible for administering this new fund have expressed “deep concern” that it apparently cannot be used by homes to purchase PPE, requires detailed and prescriptive accounting and reporting, does not cover domiciliary care and supported living schemes, resulting in “a confused and overly bureaucratic system, which makes it difficult for providers to claim and impossible for local authorities to deliver within the required timescales” (Source: https://www.adass.org.uk/media/7909/200529-adass-letter-to-minister-of-state-re-infection-control-fund.pdf). An independent analysis commissioned by local authorities estimated that providers could face over £6bn in additional costs during April to September 2020, because of higher staffing costs (mainly due to cover staff who are ill or self-isolating), PPE, and extra cleaning and overhead costs (Source: https://www.local.gov.uk/lga-social-care-providers-face-more-ps6bn-extra-covid-19-costs).
On October 1, 2020, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. Half will be paid on October 1, 2020, and the other in December 2020. Local authorities should pass on 80% of this to care homes on a per bed basis and CQC-regulated community care providers on a per user basis, both of which must be within the local geographical area. The other 20% should be used to support care providers, allocated at the discretion of the local authority. This allocation cannot be used to pay for the cost of purchasing extra PPE. Local authorities must write to DHSC by October 31, confirming they have put in place a winter plan, and that they are working with care providers in their area on business continuity plans (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).
As recently as November 3, 2020, 75 care organisations called on the government to align the Carers Allowance with Universal Credit, as it is currently in Scotland, to recognise the disproportionate impact of the pandemic on carers (Source: https://www.disabilityrightsuk.org/news/2020/november/75-organisations-again-call-government-make-carer%E2%80%99s-allowance-fairer-carers; https://www.nuffieldtrust.org.uk/news-item/what-are-carers-entitled-to).
On December 23, 2020, DHSC announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. This funding will be paid in January 2021. All funding must be used to support increased LFD testing in care settings. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority (Source: https://www.gov.uk/government/publications/adult-social-care-rapid-testing-fund/adult-social-care-rapid-testing-fund-guidance).
On January 13, 2021, NHS England (NHSE) announced that the amount that local vaccination services could claim for delivering COVID-19 vaccinations in care home settings was increasing from the original £12.58 Item of Service fee and an enhanced payment of £10. This has been increased so that first doses delivered in a care home setting from December 14, 2020, to close January 17, 2021, will carry an enhanced additional payment of £30, and doses delivered in the week beginning January 18 a payment of £20. The £10 will continue to apply for all COVID vaccinations in a care home setting between January 25 and 31, as well as for the second dose for all patients and staff who received their first dose on or before January 31. Primary Care Networks (PCNs) bringing in additional workforce between now and the end of January will be eligible to claim up to £950 per week (a maximum of £2500 per PCN grouping) (Source: https://www.england.nhs.uk/coronavirus/publication/covid-19-vaccination-in-older-adult-care-homes-the-next-stage/).
On January 17, 2021, DHSC announced the Workforce Capacity Fund, worth £120 million, which was to support local authorities in boosting staffing levels and deliver measures to supplement and strengthen adult social care staff capacity to ensure that safe and continuous care is achieved (Source: https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). This funding is available until March 31. The first £84 million (70%) will be paid in early February and the second £36 million (30%) will be paid in March (Source: https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).
On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support (the Rapid Testing Fund, the Infection Control Fund, and the Workforce Capacity Fund) was crucial in enabling the social care sector to function throughout the pandemic, and is due to expire at the end of March (Source: https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).
On March 18, 2021, LaingBuisson reported that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (Source: https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/). On the same day, the National Care Forum reported that there were announcements around additional funding for hospital discharge (Source: https://www.nationalcareforum.org.uk/press-releases/ncf-response-to-341m-additional-funding-for-adult-social-care/).
- 3.05. Long-Term Care oversight and regulation functions during the pandemic
The Coronavirus Act (March 25 and renewed on September 30, 2020) included provision to relax the responsibilities of local authorities under the Care Act 2014 to streamline their services in case of workforce shortages or increased demand. The Act also enabled rapid discharge of patients from hospital by allowing assessments to be delayed (Sources: https://www.legislation.gov.uk/ukpga/2020/7/contents/enacted; https://www.health.org.uk/publications/reports/adult-social-care-and-covid-19-assessing-the-policy-response-in-england). There was concern that the Care Act Easements included in the Coronavirus Act would be widely used to reduce care packages but only a small number of councils utilised them (Source: https://www.communitycare.co.uk/2020/04/30/eight-councils-triggered-care-act-duty-moratorium-month-since-emergency-law-came-force/). As of November 2020, the CQC reported that no local authorities were currently using Care Act Easements (Source: https://www.cqc.org.uk/guidance-providers/adult-social-care/care-act-easements-it).
The Care Quality Commission interrupted routine inspections on March 16, 2020 (Source: https://www.cqc.org.uk/news/stories/routine-inspections-suspended-response-coronavirus-outbreak). In May 2020, the CQC began to implement an Emergency Support Framework setting out its approach to regulation during COVID-19 (Source: https://www.cqc.org.uk/news/stories/joint-statement-our-regulatory-approach-during-coronavirus-pandemic). This involved suspending routine inspections of services and instead using and sharing information to target support where it’s needed and taking action to keep people safe and protect their human rights. CQC are now starting to resume some inspections in 300 random homes in relation to management of the pandemic, examining four key areas; safe care and treatment; staffing arrangements; protection from abuse; assurance processes monitoring and risk management (Source: https://whiteleyvillage.org.uk/whiteleys-covid-19-response-effective-in-all-key-areas-says-cqc/). Much will be conducted remotely and in person inspections will take place under exceptional circumstances only.
- 3.06. Support for care sector staff and measures to ensure workforce availability
The social care action plan recognised the urgent need to increase the social care workforce during the pandemic ‘to cover for those who are not in work, and to relieve the pressure on those that are’. The action plan included an ‘ambition’ to attract 20,000 people into social care over 3 months (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-adult-social-care-action-plan) .
On March 19, 2020, Social care staff were designated as ‘key workers’ to enable them to continue to access childcare once schools were closed (Source: https://www.gov.uk/government/publications/coronavirus-covid-19-maintaining-educational-provision/guidance-for-schools-colleges-and-local-authorities-on-maintaining-educational-provision).
The Infection Control Fund aims to ensure that all care workers isolating in line with guidance continue to receive their full wages and face no loss of income (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2/adult-social-care-infection-control-fund-round-2-guidance). Beyond this however, no specific financial support has been offered to social care workers.
On 6 May 2020, the Government launched a dedicated CARE app to support the social care workforce during COVID-19, offering access to guidance, learning resources, discounts, and other support all in one place (Source: https://www.gov.uk/government/news/dedicated-app-for-social-care-workers-launched).
On May 11, 2020, the Department of Health and Social Care (DHSC) published guidance on maintaining the health and wellbeing of the adult social care workforce. This placed the responsibility on employers to check in on team members regularly, especially those who are working remotely. It stated that employers should encourage teams to create a wellness action plan so that employees can identify how to address what keeps individuals mentally well at work. This additionally suggested that employers should encourage those who are identified as being extremely clinically vulnerable to stay at home. Where this is not possible, they should be supported to work in roles or settings that have been assessed as lower risk. Emergency funding from the adult social care winter plan can be used to cover the cost of maintaining income for social care staff that are currently unable to work because of self-isolation measures.
On 15 May 2020, the Government announced a new wellbeing package for social care staff delivered through the CARE app including two new helplines, led by the Samaritans and Hospice UK. This is intended to help support care staff with their mental health and wellbeing and support those who have experienced a traumatic death as part of their work or help with anxiety and stress (Source: https://www.gov.uk/government/news/care-home-support-package-backed-by-600-million-to-help-reduce-coronavirus-infections#history).
On October 1, 2020, DHSC announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, in particular by helping to reduce the need for staff movements between sites. This includes ensuring that staff who are isolating in line with government guidance receive their normal wages, limiting all staff movement between settings unless necessary, limiting the number of different people from a home care agency visiting a particular individual, limiting or cohorting staff, supporting active recruitment of additional staff, and providing accommodation for staff who proactively choose to stay separate from their families (Source: https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).
On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels (Source: https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). The aim of this is to strengthen social care staff capacity so that safe and continuous care is achieved by all providers of adult social care. This additionally stated that providers should not be deploying people in care homes if these people are being deployed to provide care in other settings, unless in exceptional circumstances. This places the responsibility on Local authorities for contacting private providers with excess capacity to redeploy these staff into other settings to best meet workforce demand. This fund can be used to pay overtime rates to encourage staff to work additional shifts, cover childcare costs to allow staff to take on hours they would usually be unable to work, and enable care providers to overstaff at pinch points to lessen the impact of any staff absences should they arise. Additionally, Local Authorities are responsible for considering whether there are trained individuals who have been made redundant from care providers which have exited the market and so would be able to transition quickly into a new care setting. There may be individuals without care experience who have recently been made redundant and may require support applying to the care sector and training (Source: https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).
On February 9, DHSC announced that the government was asking people to register their interest in taking up short-term paid work in the adult social care sector to meet urgent demand during winter (Source: https://www.gov.uk/guidance/short-term-paid-work-in-adult-social-care).
On March 3, DHSC published guidance on restricting workforce movement between care settings. This stated that staffing requirements should be planned so that routine movement is not required to maintain safe staffing levels, with mitigations such as exclusivity contracts and block booking used to minimise staff movement where temporary staff are needed. Additionally, should a provider need to deploy an individual between two settings, they should ensure a 10-day interval between the individual attending the two settings. The individual must have a PCR negative test in the 7 days before starting the placement. Additionally, this states that providers should cohort staff to induvial groups of residents and ensure staff movement is limited between these groups. Providers should take steps to limit the use of public transport by staff and discourage lift sharing arrangements (Source: https://www.gov.uk/government/publications/restricting-workforce-movement-between-care-homes-and-other-care-settings).
- 3.07. Infection Prevention and Control measures in the Long-Term Care sector: guidance, training and implementation support
Guidance for home care providers was provided relatively late in the pandemic. On April 27, 2020, Public Health England issued guidance on PPE use for care workers providing domiciliary care. In addition to hand hygiene, respiratory hygiene, and avoiding touching their face, care workers should also follow standard infection prevention and control precautions (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881296/Domiciliary_care_guidance_final.pdf).
The Government published wider guidance for domiciliary care providers on May 22, 2020, much later than equivalent guidance for other long-term care settings was issued (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care). This covered PPE, shielding of clinically vulnerable people, hospital discharge, and government and local authority support. The guidance has continued to be updated, including advice for providers to divide the people they care for into ‘care groups’ and allocate teams of staff to provide care specifically to those care groups (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care#shielding-and-care-groups).
The government issued guidance for unpaid carers, which recommends carers to develop an emergency plan with the person they care for in case the carer becomes unable to continue to provide support, to follow hygiene rules, to maintain their own health, and advice on how to react in case the person with care needs or the carer themselves develop symptoms of COVID-19 (https://www.gov.uk/government/publications/coronavirus-covid-19-providing-unpaid-care/guidance-for-those-who-provide-unpaid-care-to-friends-or-family).
Guidance for unpaid carers of adults with learning disabilities and autistic adults is very similar to the general advice for unpaid care (published on April 24,2020). There are, however, specific points raised around communication and coping with bereavement (https://www.gov.uk/government/publications/covid-19-providing-unpaid-care-to-adults-with-learning-disabilities-and-autistic-adults).
As of December 2020, government guidance for care staff supporting adults with intellectual disabilities and autistic adults (https://www.gov.uk/government/publications/covid-19-supporting-adults-with-learning-disabilities-and-autistic-adults/coronavirus-covid-19-guidance-for-care-staff-supporting-adults-with-learning-disabilities-and-autistic-adults)was last updated on November 5, 2020, which links to a range of other relevant guidance and resources. This includes more detailed guidance from the Social Care Institute for Excellence on supporting autistic people and people with intellectual disabilities, including guidance for social workers and occupational therapists, guidance for care staff, and guidance for carers and family (https://www.scie.org.uk/care-providers/coronavirus-covid-19/learning-disabilities-autism).
Government guidance has not always been accompanied by accessible versions for people with intellectual disabilities, autistic people, and family members, and several NGOs (including some financially supported by the government for this purpose) have been producing easy-read and other accessible information, resources and guidance (https://www.learningdisabilityengland.org.uk/what-we-do/keeping-informed-and-in-touch-during-coronavirus/information-and-guidance/).
- 3.07.01. Measures in relation to transfers to and from hospital, from community to care homes and between settings
One of the most controversial policy decisions taken at an early stage in the management of the coronavirus crisis was the rapid discharge of older patients from hospitals to care homes around the country without testing for COVID-19. The British Medical Journal has referred to this as a ‘reckless policy’, a sentiment echoed by the Public Accounts Committee. On 17 March 2020 the Chief Executive of the NHS, instructed managers to urgently discharge all hospital patients who were medically fit to leave in order to free up substantial numbers of hospital beds. Discharges, including to care homes, may already have been taking place at this point in readiness for the expected surge in COVID-19 admissions.
Guidance issued on March 19, 2020, in support of hospital discharge arrangements, announced that the existing North of England Commissioning Support (NECS) care home tracker, designed to facilitate rapid search for available capacity in care homes, would be expanded to cover all care homes across England. All care home providers were to sign up and use the tracker to identify vacancies from Monday 23 March 2020. Even if the available care home was not their first choice, patients were to be moved to a care home as soon as possible and could be moved to their preferred care home as soon as possible. The guidance also outlined funding to provide care for people discharged from hospital into institutional care settings irrespective of whether a care assessment had been completed or where their ordinary residence was. Care homes were to receive funding out of the NHS COVID-19 budget to expand their capacity to provide care. Funding to support people leaving hospital was renewed in August with £588m being allocated to the NHS to pay for additional support and rehabilitation for up to 6 weeks (https://www.gov.uk/government/news/more-than-half-a-billion-pounds-to-help-people-return-home-from-hospital). At this time testing capacity was limited and available primarily for patients in critical care and those requiring hospital admission with symptoms of pneumonia, acute respiratory stress syndrome or flu like illness. The guidance of 2 April was explicit that ‘Negative tests are not required prior to transfers / admissions into the care home’ (https://www.northamptonshire.gov.uk/coronavirus-updates/Documents/covid-19-care-homes-guidance.pdf).
The National Audit Office estimated that around 25,000 people were discharged from hospitals to care homes between 17 March and 15 April 2020. Using an approach which also accounted for discharges for new as well as existing residents of care homes, the Health Foundation estimated that, for the period of 17 March to 30 April, 46,700 people had been discharged to care homes, 7,700 fewer than in previous years. However, the pattern of discharges differed between residential care and nursing homes. While residential care homes saw a decrease in discharges (with 12,400 discharges) compared to previous years, nursing homes saw an increase with 17,000 discharges. National bodies representing care homes complained about homes being pressured to accept residents that had not been tested. The guidance of 2 April stated that ‘patients can be safely cared for in a care home if this guidance is followed’. However, clinicians acknowledged that it was a ‘major error’ to assume ‘that care homes could cope with isolating patients and infection control measures in the same way a hospital could’. It has been reported that the Care Quality Commission had been informed by care home managers that several hospitals discharged people to their care home despite suspecting – or even knowing – they were infected. NHS Providers, the membership organisation for NHS hospitals, has strongly rejected the suggestion that hospitals ‘knowingly’ transferred infected patients to care homes but do acknowledge that some asymptomatic patients may have been transferred early though ‘not in large numbers’. Evidence is lacking for any accurate assessment of the extent to which hospital discharges in this period led to transmission of infection into care homes and genomic analyses suggest multiple routes of ingress into care homes.
In its COVID-19 adult social care action plan published on 15 April 2020, the government declared that it was ‘mindful that some care providers are concerned about being able to effectively isolate COVID-positive residents’ and in this context set out the commitment to test all residents prior to their admission to care homes, including on discharge from hospital. In cases where the results of the test cannot be obtained in time for discharge, patients should be cared for in isolation as if they had tested positive for COVID-19. Asymptomatic patients who have tested negative should also be cared for in isolation for 14 days. The same was recommended for patients with COVID-19 symptoms and a positive test result where the patient needed to be discharged from acute NHS care within the 14-day period since the beginning of the symptoms. The action plan recognised that not all providers will be able to accommodate these individuals through appropriate isolation or cohorted care (a reality supported by a survey of 43 English care home managers), and in these circumstances the individual’s local authority will be asked to secure alternative appropriate accommodation and care for the remainder of the required isolation period. For admissions from the community, it is assumed they will be tested prior to admission and in consultation with the family, the care home can decide whether isolation is appropriate.
- 3.07.02. Approach to isolation of people with confirmed or suspected Covid-19 infections in care homes
There have been two major difficulties in identifying and isolating infected individuals effectively in care homes in England. First, guidance issued to care homes focused only on people who were displaying symptoms (initial guidance only mentioned a persistent cough and fever as symptoms). It took a long time for official guidance to consistently recognize the potential for pre-symptomatic or asymptomatic transmission (https://ltccovid.org/2020/06/12/asymptomatic-and-pre-symptomatic-transmission-in-uk-care-homes-and-infection-prevention-and-control-ipc-guidance-an-update/). Guidance on identifying residents and staff who may have been in contact with persons who had the virus and preventive isolation became available on April 2, 2020 (https://www.gov.uk/government/publications/coronavirus-covid-19-admission-and-care-of-people-in-care-homes/coronavirus-covid-19-admission-and-care-of-people-in-care-homes).
The ability of care homes to implement existing IPC guidance was hampered by a lack of access to testing (tests for asymptomatic residents and staff only started to be available after the April 28, 2020) and PPE, staff shortages and facilities that were not suitable for effective isolation or cohorting (https://journal.ilpnetwork.org/articles/10.31389/jltc.53/). Where care homes are not able to implement adequate isolation or cohort policies, it is the responsibility of the local authority to secure alternative accommodation for the isolation period, drawing on the £1.3 billion discharge funding (https://www.gov.uk/government/news/2-9-billion-funding-to-strengthen-care-for-the-vulnerable).
Ahead of the second wave, the government set up a scheme to prepare “designated settings” that could provide safe isolation for people who were discharged from hospital while positive for Covid and who needed to move to a care home. The settings had a to meet set of standards to deliver safe care for Covid-19 positive residents.
- 3.07.03. Care homes: visiting and unpaid carer policies
The initial guidance in England published on March 13, 2020, advised against visits by people who had suspected COVID-19 or were feeling unwell. The main care home chains stopped non-essential visits around that time. Although no formal ban on visits to care homes was issued, the advice was not to visit except in exceptional (usually end of life) situations (https://www.bbc.co.uk/news/52674073). The Prime Minister also announced on March 16 that the physical distancing measures should also apply to care homes. Guidance on family visits was issued on the 22 July, linking the visiting policy to local levels of risk of transmission and advising that visits were limited to a “single constant visitor” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes).
On October 1, 2020, the Department of Health and Social Care (DHSC) announced a second round of funding worth £546 million for the Adult Social Care Infection Control Fund. This is to be extended until March 2021, following on from May 2020, when the fund was initially worth £600 million. The purpose of this fund is to support adult social care providers to reduce the rate of COVID-19 transmission within and between care settings, which includes enabling safe visiting of care homes (https://www.gov.uk/government/publications/adult-social-care-infection-control-fund-round-2).
On October 13, 2020, the Care Minister announced the government’s intention to pilot a care home visitor scheme, in which designated visitors would be recategorized as ‘key workers’ and given priority access to weekly rapid antigen tests and PPE (https://committees.parliament.uk/oralevidence/1032/pdf/; https://www.bbc.co.uk/news/uk-politics-54528021).
Following the announcement of the second national lockdown, more than 60 care organisations collectively called on November 3, 2020, for safe visits to care homes to continue; a similar call was made by ADASS (https://www.laingbuissonnews.com/care-markets-content/news/organisations-call-for-care-home-visits-to-continue/). In response to the ongoing restrictions, a high court judge ruled on November 3, 2020, that visits to care homes were legal (https://www.theguardian.com/society/2020/nov/03/judge-says-care-home-residents-in-england-are-legally-allowed-visitors?fbclid=IwAR1EHVzBhTUH1E7IFqzu9eYzCN7nMnkpT8MIxhwoygL7tHQgl_glve2cok4). Following this, government guidance on visiting arrangements were updated on November 5, 2020, advising directors of public health and providers to facilitate visiting where possible in a “risk-managed way” (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus/update-on-policies-for-visiting-arrangements-in-care-homes). There is ongoing concern as to whether the arrangements are sufficiently flexible and sensitive to the needs of people in care homes and their families.
On December 1, 2020, DHSC released guidance on arrangements for visiting out of the care home, which was then updated on March 8, 2021. This stated that visits out of care homes should only be considered for care home residents of working age, and although regulations could technically allow residents to form a support bubble with another household, this is not recommended. This suggested that the assumption should be that visiting is allowed unless there is evidence to take a more restrictive approach, where the needs of the individual are balanced against a consideration of the risks to others in the home. For visits to take place, the residents and all members of the household must have had a negative result from a Lateral Flow Device immediately preceding the visit. It is suggested that those involved in the visit should limit the number of people they meet for 2 weeks prior to the visit out. Upon returning to the care home, the resident should self-isolate for 14 days. In the event of an outbreak in a care home, all outward visiting should be immediately stopped (https://www.gov.uk/government/publications/visiting-care-homes-during-coronavirus).
On January 21, 2021, DHSC released guidance for care homes during the winter. This stated that visits to care homes could take place with arrangements such as substantial screens, visiting pods, or behind windows. This stipulated that end-of-life visits should always be supported (https://www.gov.uk/government/publications/coronavirus-covid-19-support-for-care-homes).
On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, because it provided funding to allow every visitor to be tested. This support is due to expire at the end of March (https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).
On March 18, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/).
Since May 17, every care home resident can nominate up to 5 named visitors who will be able to enter the care home for regular visits (and will be able to visit together or separately as preferred). Residents with higher care needs can choose to nominate an essential care giver who may visit the home to attend to essential care needs. The 5 named visitors may include an essential caregiver (where they have one) but excludes babies and preschool-aged children (as long as this does not breach national restrictions on indoor gatherings). To reduce the risk of infection residents can have no more than 2 visitors at a time or over the course of one day (essential caregivers are exempt from this daily limit) (https://www.vilans.nl/vilans/media/documents/publicaties/covid-19-in-long-term-care-until-june-2021.pdf).
The most recent guidance (August 2021) removes the advice on the number of ‘named visitors’ and does not limit the number of visitors a resident can have in a single day. The essential caregiver should be able to visit even if the home is in outbreak (except where carer or resident are Covid-positive), or if the caregiver is not fully vaccinated.
- 3.08. Access to testing and contact tracing for people who use and provide Long-Term Care
Limitations on testing capacity meant that initial workforce testing strategy focused on NHS workers with symptoms. This was extended to social care workers (with symptoms) from 15 April 2020 (https://www.gov.uk/government/news/government-to-offer-testing-for-everyone-who-needs-one-in-social-care-settings), and on 28 April, a policy of one-off whole home testing was announced for all staff and residents of care homes with residents over 65 or with dementia and an online portal was launched on 11 May to help care homes arrange deliveries of test kits (http://www.nationalhealthexecutive.com/Health-Care-News/government-portal-care-home-testing). Although testing capacity was increasing, this was not without problems. The BBC reported that on 22 April, 159 out of 210 care providers contacted about testing reported that none of their staff had received a test (https://www.bbc.co.uk/news/health-52284281). On 12 May, the Guardian reported that care home operators accused the government of ‘a complete system failure’ regarding the promised testing in care homes. According to this article only tens of thousands had been tested so far, leaving many vulnerable people at risk. Different government agencies were accused of passing responsibilities to each other (https://www.theguardian.com/society/2020/may/12/testing-coronavirus-uk-care-homes-complete-system-failure). A survey of 43 English care home managers, which was conducted at the end of May and early June 2020, found that only 40% had accessed testing of asymptomatic residents and 50% of asymptomatic staff. At that time, only 36% of residents had been tested, with many describing a chaotic and poorly co-ordinated service (https://ltccovid.org/2020/06/09/learning-from-the-impacts-of-covid-19-on-care-homes-in-england-a-pilot-survey/). At that time, only 10% of care homes surveyed had successfully tested all residents in their care home (http://doi.org/10.31389/jltc.53).
On June 8, 2020, the Government announced that all remaining adult care homes would be able to access whole care home testing for all residents and asymptomatic staff through the digital portal, including adult care homes catering for adults with learning disabilities or mental health issues, physical disabilities, acquired brain injuries, and other categories for younger adults under 65 years (https://www.gov.uk/government/news/whole-home-testing-rolled-out-to-all-care-homes-in-england). It should be noted that these ‘whole care home’ testing arrangements do not apply to supported living settings, extra care settings, and domiciliary care. In these situations, individual tests can be applied for through self-referral. From 3 July, care home staff were promised weekly testing (https://www.gov.uk/government/news/regular-retesting-rolled-out-for-care-home-staff-and-residents), but domiciliary care staff were still only eligible for free testing if symptomatic, as the general population (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/933134/Routes_for_Coronavirus_testing_in_adult_social_care_in_England_accessible1.pdf).
In light of advice from the Government’s Scientific Advisory Group for Emergencies (SAGE) and results from the Vivaldi 1 study, regular retesting staff and residents in care homes for over 65s and those with dementia was announced to be implemented from early July (https://www.gov.uk/government/news/regular-retesting-rolled-out-for-care-home-staff-and-residents). It was reported that this had been delayed until September (https://www.thetimes.co.uk/past-six-days/2020-08-02/news/care-home-coronavirus-testing-pledge-abandoned-tqxf6mm6j), with promises of new rapid point of care tests, although these had yet to be formally approved and questions remained about the most suitable and safe tests for such a vulnerable setting (https://www.gov.uk/government/news/roll-out-of-2-new-rapid-coronavirus-tests-ahead-of-winter#:~:text=Millions%20of%20new%20rapid%20coronavirus,and%20labs%20from%20next%20week.&text=Millions%20of%20ground%2Dbreaking%20rapid,testing%20capacity%20ahead%20of%20winter).
On December 23, 2020, the Department of Health and Social Care (DHSC) announced £149 million to support the rollout of Lateral Flow Device (LFD) testing in care homes. This funding will be paid in January 2021. All funding must be used to support increased LFD testing in care settings. Local authorities should pass on 80% of this to care homes on a per bed basis, which must be within the local geographical area. The other 20% should be used to support care providers to implement increased LFD testing, allocated at the discretion of the local authority (https://www.gov.uk/government/publications/adult-social-care-rapid-testing-fund/adult-social-care-rapid-testing-fund-guidance). Care homes currently have access to 3 tests per week for their staff, with daily testing for 7 days in the event of a positive case. Care homes will have additional LFDs to test individuals working in more than one setting before the start of every shift (https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing).
On February 16, 2021, DHSC published guidance announcing that weekly COVID-19 testing is to be made available to personal assistants working in adult social care in England. These tests will be ordered online, taken at home, posted off for testing, with results available within 48 hours. After testing positive, a person does not need to test again for 90 days unless they become symptomatic. This guidance gives personal assistants responsibility for informing their employers if they receive a positive result (https://www.gov.uk/guidance/coronavirus-covid-19-testing-for-personal-assistants).
On January 17, 2021, DHSC announced a £120 million Workforce Capacity Fund to help local authorities to boost staffing levels (https://www.gov.uk/government/news/social-care-to-receive-269-million-to-boost-staff-levels-and-testing). The aim of which is to strengthen social care staff capacity so that safe and continuous care is achieved by all providers of adult social care. If the specific way in which staff capacity is strengthened means that they do not have access to routine to routine asymptomatic testing or LFD testing, then it is suggested that the local authority could use their allocation of LFD tests for routine testing (https://www.gov.uk/government/publications/workforce-capacity-fund-for-adult-social-care).
On March 5, 2021, DHSC published guidance on LFD testing in adult social care settings. This stipulated that it is necessary to obtain consent before residents and staff are tested and their results shared. If a person receives a positive result from a LFD, then they will need to take a confirmatory PCR test and immediately self-isolate. With a negative test, the person can stop self-isolating but must continue to follow national and local rules and guidelines (https://www.gov.uk/government/publications/coronavirus-covid-19-lateral-flow-testing-in-adult-social-care-settings).
On March 12, 2021, Nuffield Trust released analysis explaining that there was no mention of social care in the budget announced by the Chancellor. Short-term emergency support in the form of the Rapid Testing Fund was crucial in enabling safe visits to occur in care homes, which is due to expire at the end of March (https://www.nuffieldtrust.org.uk/news-item/social-care-reform-running-out-of-time-and-money).
On March 18, 2021, LaingBuisson announced that an extra £341 million was to be provided to support adult social care with the costs of infection prevention control and testing so that visits can be carried out safely. This commitment was for a three-month period. There was no mention of an extension to the Workforce Capacity Fund (https://www.laingbuissonnews.com/care-markets-content/news/adult-social-care-to-receive-extra-funds/).
- 3.09. Access to Personal Protection Equipment (PPE) in the Long-Term Care sector
The Government has faced criticism and legal challenges for failures in the availability and distribution of PPE, particularly in the early phase of the pandemic. There was a significant shortage of PPE (face masks, aprons, gloves and visors). Furthermore, the central stockpile was designed for a flu pandemic (https://www.nao.org.uk/wp-content/uploads/2020/06/Readying-the-NHS-and-adult-social-care-in-England-for-COVID-19.pdf; https://goodlawproject.org/news/the-ppe-fiasco/). In the view of the British Medical Journal, the Government ‘failed to protect staff in the NHS and social care by not delivering sufficient amounts of personal protective equipment (PPE) of the right specification, again deviating from WHO advice’ (https://www.bmj.com/content/369/bmj.m1932). Directors in the social care sector specifically pointed to ‘a critical lack of PPE and testing of social care staff and service users is putting them at unnecessary risk of exposure’ (https://www.adass.org.uk/statement-by-adass-and-unions-on-ppe-in-the-care-sector). Resentment about prioritisation of the NHS for distribution of PPE has been expressed (https://www.ft.com/content/6afb06d6-abd6-4281-ac16-74f500f096d0).
Initial steps announced on 18 March 2020, included the distribution of PPE to every care home and care home provider to ensure that they had at least 300 fluid repellent face masks for immediate needs, followed by a further tranche of items of PPE in early April (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). However, the government did acknowledge PPE supply shortages and published a PPE plan on 15 April with the goal that ‘everyone should get the personal protective equipment (PPE) they need’ (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan). Announcements by the government about the number of items of PPE being delivered have been questioned. According to the BBC, over half of the 1.2bn items of PPE the Department of Health’s announced on 10 May for health and social care providers in England were surgical gloves, with gloves individually counted rather than in pairs (https://www.bbc.co.uk/news/health-52254745) and faulty equipment subsequently being recalled (https://www.carehomeprofessional.com/recall-notice-issued-for-faulty-ppe-masks-sent-to-care-homes/). It is not clear how the protective equipment delivered was divided between health and social care and there have been suggestions that delivery systems have been failing to provide to care homes, requiring them to secure their own supplies individually. One example reported was that of a care provider who was provided with 400 face masks while requiring over 35,000 masks a week (https://www.theguardian.com/world/2020/may/09/uk-care-homes-scramble-to-buy-their-own-ppe-as-national-deliveries-fail). In the survey of English care homes at the end of May and early June mentioned above, 70% of care home managers reported insufficient PPE supplies, with 34% of providers purchasing supplies directly from abroad.
In the social care sector providers have traditionally organised the PPE they required through the market. The adult social care action plan announced that the Government was now stepping in with arrangements to support the supply and distribution of PPE (https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/879639/covid-19-adult-social-care-action-plan.pdf). A parallel supply chain has been established for emergency PPE provision, involving new logistics networks and support from the army and including a national supply disruption response (NSDR) system to respond to emergency PPE requests, and a 24/7 helpline for providers who have an urgent requirement (https://www.gov.uk/government/publications/coronavirus-covid-19-personal-protective-equipment-ppe-plan/covid-19-personal-protective-equipment-ppe-plan).
- 3.10. Use of technology to compensate for difficulties accessing in-person care
A considerable proportion of unpaid carers in the UK reported to have used technology for social contacts, a smaller proportion for health and LTC services. The use of technology for remote support received mixed feedback (see, for example: https://www.carersuk.org/images/News_and_campaigns/Behind_Closed_Doors_2020/Caring_behind_closed_doors_Oct20.pdf; https://bmcgeriatr.biomedcentral.com/articles/10.1186/s12877-020-01719-0; https://www.tandfonline.com/doi/full/10.1080/13607863.2020.1822292; http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf). On the other hand, a report by Age UK has found that there was no significant change in the use of digital engagement during the first few months of the pandemic. The main barrier reported for peopled aged 75 and older was ‘lack of digital skills’ (https://www.ageuk.org.uk/globalassets/age-uk/documents/reports-and-publications/reports-and-briefings/active-communities/digital-inclusion-in-the-pandemic-final-march-2021.pdf).
A press release by the Department of Health and Social Care on April 24, 2020, described that they, together with the Ministry for Housing Communities and Local Government, had awarded up to £25,000 to 18 innovative digital solutions as part of the TechForce19 challenge. Among these, one app that received funding aims to ‘help carers identify health risks and deterioration within elderly communities’ (https://www.gov.uk/government/news/digital-innovations-tested-to-support-vulnerable-people-during-covid-19-outbreak).
Research accompanying the virtual Cuppa project, which offered unpaid carers the possibility to connect virtually for half an hour on weekdays with others in similar situations facilitated by a professional carer coach, found that over time carers developed friendships with other members of participating in the project, shared resources and experience, and that the virtual Cuppa group became ‘a resource in its own right to develop individual resilience’ (p.22) (http://circle.group.shef.ac.uk/wp-content/uploads/2020/11/007_Aspect-Virtual-Cuppa-Report-4-compressed.pdf).
- 3.11. Vaccination policies for people using and providing Long-Term Care
On November 27, 2020, Public Health England (PHE) published their COVID-19 vaccine guidance for health and social care workers (https://www.gov.uk/government/news/phe-publishes-covid-19-vaccine-guidance-for-health-and-social-care-workers). On December 7, NHS England (NHSE) published a standard operating procedure on vaccine deployment for care home staff. This gave care home providers the responsibility to inform their staff, organise logistics, and encourage vaccine uptake (https://www.england.nhs.uk/coronavirus/publication/standard-operating-procedure-covid-19-vaccine-deployment-programme-hospital-hub-care-home-staff/).
On December 20, NHSE published information stating that a roving model to deliver the vaccine in care home settings was to be deployed as soon as possible. (https://www.england.nhs.uk/coronavirus/publication/staffing-support-to-deliver-the-covid-19-vaccine-to-care-home-residents-and-staff/). On December 30, NHSE published information which stipulated that vaccines should still be offered to older adults in care homes which have cases, although for those who are acutely unwell or within four weeks of the onset of COVID-19 symptoms, this should be temporarily deferred (https://www.england.nhs.uk/coronavirus/publication/guidance-for-covid-19-vaccination-in-care-homes-that-have-cases-and-outbreaks/).
On December 30, the Department of Health and Social Care (DHSC) published information on vaccination priority groups. Previous publications by the Joint Committee on Vaccination and Immunisation (JCVI) had stated that the first priority group for receiving COVID-19 vaccinations were residents in care homes for older adults and their carers. Frontline social care workers, including those who work in hospice care, are to be included in the second priority group. Carers of those with an underlying health condition should be offered vaccines alongside these groups, which is group six unless the person they are caring for is in a higher group (https://www.gov.uk/government/publications/priority-groups-for-coronavirus-covid-19-vaccination-advice-from-the-jcvi-30-december-2020).
On January 7, 2021, NHSE published additional operational guidance, further to the guidance from December 30, 2020. This stated that by mid-January, NHS Trusts would be established as hospital hubs, which were the default provider of COVID-19 vaccinations for all healthcare and social care workers. Significant progress is expected to be made by the first week of February, with vaccinations being provided 7 days a week (https://www.england.nhs.uk/coronavirus/publication/operational-guidance-vaccination-of-frontline-health-and-social-care-workers/). On January 11, DHSC published an update to their vaccine delivery plan. This aimed to have offered a first vaccine to everyone in the top 4 priority groups by 15 February. This stated that local vaccination services had a responsibility to coordinate and deliver vaccination to people who were unable to attend a vaccination site, such as the homes of housebound individuals, and residential settings for people with learning disabilities or autism (https://www.gov.uk/government/publications/uk-covid-19-vaccines-delivery-plan).
On January 13, NHSE published information regarding the next stage of the vaccine rollout in older adult care homes. The addition of the Oxford/AstraZeneca vaccine to the schedule from the w/c January 4 meant that smaller care homes could be vaccinated. First doses were expected to be administered to care home residents and staff by January 17, and by January 24 at the latest. This was to occur 8am to 8pm, 7 days a week. It was suggested that primary care networks had a responsibility to provide mutual aid to other PCNs to ensure that all care homes had been vaccinated by the end of the w/c January 18 (https://www.england.nhs.uk/coronavirus/publication/covid-19-vaccination-in-older-adult-care-homes-the-next-stage/). On January 14, NHSE published an update outlining the next steps for eligible social care worker vaccination. This reported that a national booking system was to be made available for eligible social care workers to self-refer. Until February 28, eligible staff will be able to self-book a vaccination (https://www.england.nhs.uk/coronavirus/publication/vaccinating-frontline-social-care-workers/).
On January 26, the National Care Forum (NCF) carried out a snapshot survey across 750 care homes for older people in England between January 25 and 26. Of these 750, 715 had achieved whole home vaccination, representing 95% vaccine take up. Whilst most organisations who responded noted that 50% or more of staff had been vaccinated, only 27% reported vaccination over 70% for their staff. The NHSE target to vaccinate all residents and staff by January 24 has been missed, and the next goal is the government objective of getting all those in JCVI groups 1-4 vaccinated by February 15 (https://www.nationalcareforum.org.uk/ncf-press-releases/vaccine-take-up-in-care-homes/). On February 15, the BBC reported the announcement from the Health Secretary that a third of social care staff in England had not had the COVID-19 vaccine. Everyone in the top four groups had been offered the COVID-19 vaccine (https://www.bbc.co.uk/news/uk-56065986).
On February 24, PHE reported that the JCVI had advised that all people on the GP Learning Disability Register were to be invited for vaccination as part of the JVCI group 6 (people with Down’s syndrome are included in group 4) (https://www.gov.uk/government/news/jcvi-advises-inviting-people-on-learning-disability-register-for-vaccine). On March 8, NHSE published an operating procedure relating to COVID-19 vaccine deployment for unpaid carers who will now be part of the JCVI cohort 6. Where the person they care for is part of the JCVI vaccine cohort 6, then they are able to receive their vaccination at the same time (https://www.england.nhs.uk/coronavirus/publication/sop-covid-19-vaccine-deployment-programme-unpaid-carers-jcvi-priority-cohort-6/?dm_t=0,0,0,0,0).
On March 10, Nuffield Trust released some analysis. This showed that by the end of February, fewer than 3 in 4 staff working in care homes for older adults had received their first dose. This showed regional variation, with rates highest in the North East and Yorkshire and lowest in London. Rates for other social care staff are even lower with fewer than 3 in 5 having had their first dose (https://www.nuffieldtrust.org.uk/resource/chart-of-the-week-variation-in-vaccinating-the-health-and-social-care-workforce).
On March 22, The Telegraph reported that leaked details of a paper, ‘‘Vaccination as a condition of deployment in adult social care and health settings’, submitted to the Covid-19 Operations Cabinet sub-committee showed that the Prime Minister and the Health Secretary had requested that vaccinations become a legal requirement for care home workers. The legal change would be likely to affect England only, with health policy the remit of the devolved administrations in Wales, Northern Ireland, and Scotland. Only around a quarter of care homes in London, and half in other parts of England, have reached the level of vaccination among staff and residents deemed safe by government scientists, which SAGE set at 80% vaccination among staff and 90% among residents of a care home (https://www.telegraph.co.uk/politics/2021/03/22/care-home-staff-face-compulsory-covid-vaccination/).
On 4th August 2021 it was announced that full Covid-19 vaccination would be mandatory for staff working in care homes by 11th November 2021, despite concerns from providers that this may worsen existing staff shortages.
By 29th August 2021, 95% of all eligible residents and 82% of staff in older adult (65+) care homes had had a second Covid-19 vaccine dose. 78.7% of all care homes in England had had at least 80% staff and 90% residents vaccinated with at least one dose. Among younger adults living in care homes, 88.9% had had a second dose (https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-vaccinations/).
- 3.12. Measures to support unpaid carers
After few measures to support unpaid carers initially, support for unpaid carers increased over time. This included specific guidance for unpaid carers, enabling unpaid carers experiencing symptoms to be tested; providing unpaid carers should with letters enabling to identify needs related to carer role. A major source of support for many working carers was the furlough scheme that enabled them to maintain up to 80% income.
Carers were included in priority group 6 for COVID-19 vaccination.
The government provided additional funding for the Carer UK helpline.
PART 4 – Reforms to address structural weaknesses of Long-Term Care systems and to improve preparedness for future pandemics and other emergencies
- 4.02. Reforms to the Long-term care financing system
On 7th September 2021 the Prime Minister announced a social care reform plan to cap the costs of social care, with the aim of protecting people against catastrophic costs of care. This is to be funded through a new UK-wide 1.25 per cent Health and Social Care Levy that will be ring-fenced for health and social care, based on National Insurance contributions. This levy will be applied to all working adults, including those over state pension age. Of the £36bn that will be raised through this mechanism, only £5.4bn will be for social care (spread over 3 years).