On 6 March, as the World Health Organisation told all countries to make containment of the novel coronavirus “their highest priority”, Matt Hancock sent a letter to MPs and peers.
The Health Secretary was seeking “proposed solutions” to the UK’s crisis in social care, an issue that has haunted politics for many years. Sent the day after Italy banned all visits to care homes, the letter was, in effect, a concession that — despite 20 years of green papers, white papers, royal commissions and independent reviews — the 2020 budget would not contain a long-term plan for the funding of social care.
While an ageing population constantly increases demand, real-terms spending has fallen dramatically. Successive governments have failed to address the well-known problems in social care, and the coronavirus pandemic has laid bare the consequences.
Figures from the Office of National Statistics are beginning to reflect the abysmal damage wrought by the coronavirus pandemic on this underfunded and overlooked sector. In England and Wales, the number of people dying of Covid-19 in care homes has more than quadrupled in the space of a week; the rate of deaths from Covid-19 in care homes is now rising at a faster rate than those in hospitals.
From interviews with carers, care home managers and GPs, the New Statesman has found evidence that these figures drastically underestimate the true impact of coronavirus in the UK’s care homes.
This is corroborated by data analysis which shows the number of non-Covid-19 deaths has greatly increased. Our reporting suggests that death certificates which read “pneumonia” or other general respiratory problems, rather than coronavirus specifically, mask the disease’s true impact.
Graph by Nicu Calcea
Separate data from Public Health England, which monitors respiratory outbreaks as part of its weekly flu reporting, shows a huge rise in respiratory outbreaks in recent weeks, with the vast majority occurring in care homes.
Graph by Michael Goodier
The widescale failure to record Covid-19 on the death certificates of care home patients is the result of two factors. Firstly, there is a lack of testing available for care home residents and patients discharged from hospitals to care homes. Secondly, both government and private care providers have a strong incentive to keep nursing homes open for business.
“Normally, on all the death certificates, it says pneumonia, dementia,” says Rachel*, 57, a carer who has worked in a care home in Essex for eight years. The home currently has 78 residents. In recent weeks, seven people on the dementia unit have died after showing Covid-19 symptoms, but only one – who was sent to hospital and back twice – was tested. The test was positive.
Now the virus appears to have spread to another of the care home’s four units. Rachel says that the company that manages the care home “keep insisting we haven’t had an outbreak, as if we’d always have this many deaths”. But she is convinced there is a growing outbreak in her workplace: “These people had the symptoms – temperatures, coughs, everything else, but they’ve chosen to ignore it. If this was normal circumstances and we had that many deaths in one week, we’d be investigated and possibly shut down.”
Graph by Nicu Calcea
Jenny*, a care home manager in Wiltshire, has run her care home for 15 out of her 30 years working in the care sector. She calls the official figures an “underestimate”. “Every care home’s got it,” she says. One of Jenny’s residents died of Covid-19 on Monday, having tested positive. Another has since been confirmed to have contracted the virus.
“It will be interesting to see what they put on the death certificates – they’re elderly, in their eighties, nineties, there are lots of causes of death that I would still attribute to Covid,” she says.
But despite alerting Public Health England of her two cases, she says she was not advised to close the care home to new patients. “Usually if we have two or more cases of, say, norovirus, they close the home down with an official outbreak,” she says. But this time, they haven’t. Jenny believes “they still want us to take admissions”.
The New Statesman has approached Public Health England about its guidance on this issue.
Under pressure to address the spread of coronavirus in social care settings, Matt Hancock used the Wednesday 15 April press conference to announce a raft of new measures.
“From the moment of the emergence of coronavirus, we’ve known that some of the most vulnerable to this disease are in social care,” said Hancock. “And we’ve been taking action right from the start.”
However, the government’s official guidance on social care up until 13 March stated: “It remains very unlikely that people receiving care in a care home or the community will become infected.” This was the same day that the WHO identified Europe as the centre of the pandemic, that Spain declared a state of emergency, and that the UK recorded its 798th case of coronavirus.
As coronavirus began to spread in the UK, politicians and the NHS were desperate to free up hospital beds. A race to discharge patients from hospitals back into the community began.
“Going back a few weeks, we were getting mathematical modelling that was basically showing the numbers of cases were going to go through the roof, and they were going to hugely exceed the hospital capacity that we have,” recalls Dr Phil Whitaker, a GP based in Radstock, Somerset, who has written of his own experience with one care home Covid-19 patient. “So in our area, I think all around the country, everybody went into a huge drive to empty hospitals.”
Usually when patients are discharged to care homes, there is an assessment of their needs and where it might be appropriate to place them before they leave hospital. But when coronavirus hit, “they flipped that model round”, says Whitaker.
“There may well have been some people who were pushed out into care homes quickly, supposedly as non-Covid patients – but nobody could say for sure, they weren’t tested – who were virally shedding.
“I definitely know in our area, people with proven coronavirus who were on the recovery track – the frailer people, who had maybe come in from a nursing home in the first place – were being discharged as known positive cases into nursing homes.”
The idea was that these patients would be isolated with “barrier nurses”, as they would be in a hospital. But the protective equipment was not in place to do this effectively in care homes. “That’s the part I think is scandalous,” says Whitaker.
Jenny, the Wiltshire care home manager, says she often admits hospital patients when there is pressure for beds in winter. When she received two admissions from hospital a few weeks ago, one later tested positive for Covid-19.
“One of my admissions from hospital most likely brought the Covid into my home,” she says. “They didn’t know they weren’t positive [but] they discharged them into care homes, who have the people who should be shielded the most… These are the most vulnerable people, they’ve got all the underlying health conditions, and they’re elderly. So they’re sitting ducks.”
Rachel, too, traces the outbreak of Covid-19 she suspects is taking place in her care home in Essex to one resident who returned after two days in hospital, having shown symptoms of coronavirus three weeks ago. “Since then,” she says, “seven people on that same unit have died.”
A source at NHS England confirmed to the New Statesman that there was “an effort before coronavirus was circulating widely” to discharge hospital patients into social care. Official guidance continues to recommend that patients are discharged to wherever is safe and appropriate.
“It’s like everyone’s attention was in one direction, and behind them was a nursing home up in blazes,” says Whitaker.
This focus on hospitals and NHS patients reflects our two-tier health system. Care outside of the NHS is run by stretched local authority social care budgets for those who cannot afford their own care, private providers who run care homes and private agencies that supply care in the home.
Geriatric care has been “moved into the nursing home sector, which obviously has financial benefits to the NHS,” says Whitaker. “Some of them [care homes] do attract NHS funding actually, depending on the level of dependency, but the care of that population has effectively been outsourced into the private sector.”
On 15 April, Matt Hancock said that any carer who needed a test would be able to have one, and that all symptomatic care home residents would be tested. Remarkably, such testing had not been happening before.
But our reporting has found that care homes have still not been able to access testing, more than a week later.
“We had a spate of residents with high temperatures,” says Robin Hall, the bursar of a charitable care home in Portsmouth. “A GP reported that to Public Health England. They came in and swabbed three of those patients for Covid-19. They then told us that they would only do three and no more.” All three of the swabbed patients tested positive for Covid-19.
Even if, as the Health Secretary asserted, “all symptomatic care home residents” could be tested, an estimated 350,000 people receive care in their own homes. These people continue to be refused tests.
Jess Hall, who works for a domiciliary care company in Staffordshire, sent one service user to hospital with Covid-19 symptoms this week. “They sent him home with a diagnosis of pneumonia and would not test him because he was not staying in hospital.”
Hall is concerned more generally that people being cared for in their own homes are not being seen by doctors. “We’ve been ringing 111 and the advice we’ve been given is to isolate them and to treat them for a normal cough – warm water, honey, lemon.”
Testing for staff also remains a big problem. Two days after Hancock’s social care announcement, Margaret Hodge, the MP for Barking and Dagenham, contacted homes across her constituency to see if the tests promised by Hancock were making their way to the frontline.
“We think there are about a thousand people either in a care home or being cared for at home,” she says. “Just crudely, I reckon that’s about 3000 staff. As of last Friday, the number of staff working in social care who had been tested was 26.”
One reason so few carers were being tested in Barking was that test were only available at the O2 centre in Greenwich, six miles away. “You’ve got knackered staff who have worked 12-hour shifts on low pay and they are dependent on public transport,” says Hodge. “You cannot test that way.”
Similarly at the Wiltshire care home, staff were told they would need to travel to Bristol for a test.
It has become apparent that, despite the government increasing the capacity for testing, it has not increased the availability of tests. Stories of carers having to travel miles for a test have become commonplace.
“We got an email on Friday saying we would be able to book our staff in for drive-thru tests,” says Robin Hall. “I got very excited until matron asked me if I’d looked at it closely… In order to get their tests, staff had to go to Gatwick, and we are in Portsmouth. It just feels like the whole system has been set up by someone who has absolutely no understanding of the world of social care. Because the majority of our staff don’t drive.”
Testing is also frustratingly out of reach in the Midlands. “We are able to send staff for tests,” says Jess Hall. “But at the moment the nearest testing centre is 33 miles away.”
At a press conference on Tuesday 21 April, Hancock acknowledged the problem of access to testing, and suggested that a move towards mobile testing was imminent.
Liz Kendall, Labour MP for Leicester West and the shadow minister for social care, says carers have told her about “being asked to go from Peterborough to Stansted for their tests, and from Norfolk to Sheffield… Simply asserting a number is not enough. You need a plan for how you’re going to deliver it.”
Despite Hancock’s reassurances that there would be an increase in personal protective equipment (PPE) supplies to the social care sector, supplies remain desperately short.
This is of particular concern in the domiciliary care sector, where carers move from residence to residence, home to home, in the full knowledge that they may well be putting not only their own lives at risk, but also those of the people for whom they care.
“We now have to wear the same very sub-standard mask all day instead of changing it for every domiciliary visit,” says one carer working for an agency in the south of England. She is far from alone.
“They [our agency] told us we don’t need masks, we’re not using them on public transport,” says another care worker for a north London agency, who travels four days a week by bus to visit his six clients at their homes. “They closed the office so I’m supposed to get some equipment in the post… I still haven’t had my delivery.”
Paid the minimum wage of £8.72 and hour, on a zero-hours contract with no cover for dropping shifts, he has no option to continue working in these conditions.
Jess Hall says she has had to tell staff “to wear one mask for a whole shift. Per staff member, that could be twelve different calls a day”.
“We had 300 masks delivered from the pandemic stockpile about three weeks ago. If we wore PPE as we should, that wouldn’t even last us a day. We carry out 344 calls a day.”
In Essex, Rachel – who also earns minimum wage – is buying and making her own protective gear. “I’ve been begging, stealing and borrowing, buying, making masks and stuff for my staff, because we’re not given it,” she says.
Recently, the entire site ran out of wipes, and a resident had to be washed using paper towels. One carer in the unit where suspected coronavirus has killed seven residents had to wear an apron around her head.
Staff have only been given three boxes of gloves between then, and four boxes containing 200 masks each. “I’ve just worked out for seven days that would mean each member of staff could only use four – and that’s only day staff.”
Now, two managers and the husband of another worker have contracted the virus. “And they’re still saying, ‘We haven’t got corona in this care home’ – it’s ludicrous,” she says. “They’re just trying to pull the wool over our eyes. I think they think we’re thick, because we’re carers.”
Analysis by the GMB union last year showed that of the 795,000 carers working in the private sector, more than half (55 per cent) are not entitled to a single day of sick pay a year.
The charity Skills for Care says around a quarter of the UK’s carers are on zero-hours contracts. “What our members are facing is a maximum risk to their own lives for minimum wage and minimum sick pay,” says Lola McEvoy, a GMB union organiser for the NHS. “Why are we expecting the lowest paid in our society to burden the biggest risk?”
The crisis has made clear that low pay is a public health issue. One young care worker from Leeds told us she is debating whether or not she would go into work if she started displaying symptoms, because her employment support is so weak. “I wouldn’t be able to afford to self-isolate,” she says. “I’ve been picking up extra shifts to save in case I have to. I live with another person, so I would have to self-isolate for two weeks which I just can’t afford.”
This is echoed by Rachel in Essex, who is on medication that suppresses her immune system. “Until my doctors signed me off last week, I was going into work,” she says.
Many carers either earn so little or work so few hours that they are not even eligible for statutory sick pay. When coronavirus first began spreading, Rachel self-isolated for a week with a cold. Unable to claim even the statutory sick pay of £94.25 a week (which rose to £95.85 in April), her responsible action cost her £350.
One care worker in Scotland who has secured a test was told by her employer that she “cannot work, and won’t be paid” in the 48 hours before she receives a result.
“Unlike in other public services, such as the NHS or local government, in social care people feel under financial pressure to come into work when they should be following the public health guidance,” says Gavin Edwards of the union Unison.
“History will remember that we drafted our lowest-paid workers to face down this virus without protection,” says GMB’s Lola McEvoy.
At Prime Minister’s Questions this week, Dominic Raab admitted that he did not know how many carers had died. But speaking to carers, it is clear that the virus is taking a heavy toll. Jess Hall told us one member of her staff “is frightened to give her children a hug and a kiss” when she arrives home from a long shift, “because of the lack of PPE”.
There is a horrifying logic to what will happen next. “I’m getting to the point where I’m not feeling safe,” says the young care worker from Leeds who, for the past two days, has been one of only two people caring for 24 residents. The carer working for an agency in the south of England confirms that “all agencies are currently short-staffed… I’m also pretty sure that some carers will probably start to refuse to work.”
Last month, when the Spanish government sent its army to disinfect care homes, soldiers stumbled upon scenes that were as nightmarish as anything they might expect to see on a battlefield. Residents had been abandoned to die by staff who had been too ill or too afraid to go to work.
The carer from Scotland says the government has “failed our residents and let them die unnecessarily, and we – the carers – have had to watch them die. We have to sit with them because their sons and daughters mostly fall under the high-risk category and can’t be with them.”
The forbearance shown by the care sector has been quite astonishing. Despite lacking PPE, despite lacking testing, despite lacking a decent salary, carers have still gone in to work. But everyone has their limits.
The head of one care home estimated that half of the staff she had self-isolating were only doing so because they were too scared to come into work. The unions have begun working out what to do in the event that one of their members refuses to show up.
“It is case-by-case basis,” says Lola McEvoy of GMB. “If there was a situation – which hasn’t happened yet – where somebody was refusing to work, we would obviously take that up on their behalf because they are entitled to PPE. But what we’ve seen so far is that people are risking their own health to care for these people.”
“We support our members in exercising their individual rights — of course we would,” adds Gavin Edwards of Unison. “We want to make sure that all of our members are not put in a position where they’re put into danger at work. The way to solve that problem is to get that PPE to the places it’s needed in social care.”
To date, the government’s most visible commitment to carers has been a green badge, which Matt Hancock unveiled during the press conference of April 15. “This badge,” he said, “will be a badge of honour in a very real sense.”
As one care worker we spoke to responded: “We are the bottom of the bottom. So don’t try and tell us we’re important, don’t say ‘thank you’ – this is your responsibility. Respect us and protect us.”
Public Health England and NHS England were approached for comment on claims in this piece.
*These names have been changed on request of anonymity.