Thread by @mancunianmedic

HERESY WARNING
Re Care Home Covid Deaths

Once a particular narrative, framing, received wisdom takes hold in media/public consciousness it is hard to shift or challenge and ands up looking heretical or uncaring but I *do* think this issue needs a slight re-balancing

The decisions to transfer residents from acute hospitals, with or without suspected Covid-19, with or without a test or a test result, back in the first weeks of the pandemic in March were *not* made by ministers or NHSE or PHE officials but my local clinicians and ops managers

that is how things work - medics make decisions on admission and discharge, and managers/clinician-managers in operational roles help set an overall atmosphere and system and negotiations with local community partners around arrangements

Sure, when letter came down from NHSE CEO and COO on 17th March urging acute trusts to reconfigure operations, clear more acute beds etc. it might have confirmed to local teams they were already on the right track but pretty much everything in that letter we were already doing

Just as most of the credit for that radical transformation of local services (e..g tripling of ICU capacity, separation of ED/AMU streams and bed base into "hot" and "cold",) sits with local teams not central agencies, we should own many actions re rapid transfer to care homes

And in the context of March and early April when we were snowed under with very sick people with respiratory manifestations of Covid-19. where we all thought (as did national and local models) we risked Italy/NYC style overwhelm, it was absolutely understandable to want beds free

The proposition of working with local community health and social care services to try and get more people into community hospitals, home with intermediate care or home care support, back to care homes they lived in or into new care home placements seemed right and reasonable

Of course a letter coming from PHE/NHSE on 2n April saying that there was no need to wait for Covid testing may have given air cover for what we were already doing but it wasn't the main driver as we were well underway

and of course new permissions/money around Coronavirus act were an accelerator or enabler but I don't think loads of acute medics and managers were being pushed into discharging people against their better judgement

then we come to testing. I know March might seem like another country by now but back then, even in acute care, testing capacity was very limited to begin with and even for people where clinically we *knew* they had Covid-19 it was hard to get tests and those test took days

and remember that Covid-19 tests have an initial "false negative" rate estimated at anything from 20 to 50% and many people initially test negative when it is obvious they have Covid-19 or when they subsequently go on to test positive a few days later

at the same time, by later March and into April once we *were* able to test most admitted patients and turn round results more quickly, we saw many patients who did *not* have any typical (as we then thought) Covid-19 features and came with other problems yet *still* tested +ve

being novel virus with a lot of emerging science, it was not clear precisely how long someone would remain infectious to others and capable of transmitting or how long they would typically wait to test negative having initially tested positive to 7 or 14 days were best guesses

It was also perfectly possible that someone could leave hospital having tested negative, but then test positive 5 or 7 days later in a care home having been "cleared" to leave.

And possible that by keeping them in hospital we would avoidably expose them to catching Covid-19

so if we think about counterfactual, the road not taken, what we should or could have done instead in a context where we did not have testing capacity at scale or speed, the notion of keeping thousands of care home residents stranded in acute hospitals waiting for serial tests

and keeping them in those acute beds when there was no acute medical treatment required in many cases and whilst everyone was understandably concerned about the acute bed base being overwhelmed would not have looked great either

Not to mentionbeing stuck in a busy, noisy, unfamiliar environment of an acute hospital ward is not what most care home residents (many with dementia, severe frailty, sensory/functional impairment, dependence, multiple conditions and at risk of harms of hospitalisation) want/need

and in this case, it would have been compounded by bans on visitors. And remember even in non pandemic times around 1 in 4 or 1 in 3 residents will die during admission

The other context is that for several years before the pandemic there had been a major (and welcome) push to support more care home residents more of the time to remain at home and out of hospital or leave hospital sooner

via advanced care planning (yes, including "non conveyance to hospital, DNACPR/ReSPECT decisions but broader than that) and enhanced health care support/in reach from community health services/primary care, crisis teams, palliative care teams. *good* practice we wanted more of

and there was a more general push - especially given England/UK very low and very full acute bed base, and rising/record numbers of delayed transfers of care not to have patients stranded in acute hospital beds who were receiving no acute hospital treatment

and an equal push to assess more people at the acute front door and try to manage them in community/ambulatory care. This was a local and national direction of travel

so if we go back to March/early April context it would have gone against every grain to start using acute beds to cohort large numbers of care home residents waiting for Covid tests which were unreliable, of uncertain significance, initially hard to get and slow to turn round

Also important to realise you can have "zero deaths in care homes" if you admit all the residents with Covid to hospital or keep them in hospital for weeks. The deaths could still happen in residents who were now in hospital (even though we *can* count this as @HealthFdn have)

And important to realise that across Western Europe (Germany exempted) even in nations with better resourced, better bedded health and care systems than UK, Covid-19 care home death numbers have been high - this has not been a problem unique to the UK

So do I think there were no mistakes or no avoidable deaths? Absolutely not!

But they lie outside much of now accepted narrative about this isssue

1 The existing structural problems of an underfunded, fragmented, short staffed social care system with variable support from and variable integration with NHS services (which those of us in the Health and Care sector have campaigned on for years)

2. The failure of pandemic preparedness after Cygnus and other reports so we did not have sufficient PPE. testing capacity etc
3. The slowness out of the blocks with national policy in Jan/Feb after WHO declared a pandemic
4. Failure to adopt successful/recommended approaches

e.g. mass testing, contact tracing, isolation, earlier lockdown etc or follow WHO guidance

5. Insufficient alternative "step down" or "discharge to assess" capacity so that new or returning care home residents could be quarantined/observed/tested away from acute bed base

6. In local (and national) escalation plans, i think assumptions were made about care home's ability to isolate or prevent outbreaks
7 Insufficient regard was taken of their significant workforce challenges (including reliance on agency staff working multiple sites)

8. Insufficent access to PPE (with the NHS having prior claim and the size and clout and supply chain in a national organisation vs a fragmeented, marketised sector with 11,000 homes and 5,000 provides)

9 Preferable if the care home sector, social care leads, inc local Public Health and Specialist infection control teams had been fully involved in fast moving local escalation plans/policies and in national guidance/permissions rather than assumptions being made& them done unto

10 All of thismiles from headlines about eugenics or older people people "sent to their deaths" or "abandoned to die" by cruel uncaring managers and officials hell bent on "eugenics" or a "cull". These were decisions made in good faith & context some of which now look misguided

and those of us who have been looking after older people with Covid-19 (whether in acute hospital or care homes, or community health teams or at home) know that when this virus hits those with frailty, multiple long term conditions, age related disability, dementia it hits hard

they often do very badly and often die, whatever we do because that is the nature of the disease. Remember care home residents have a median survival of 15-18 months from admission and c 1 in 3 die each year because they are in most cases people near the end of life

the notion that they would be candidates for ICU, ventilation or even successful CPR is wrong in most cases. And supporting someone to die in familiar surroundings with familiar staff who care about them rather than in an unfamiliar hospital ward is not being "abandoned"

ENDS