Coronavirus: lessons learned to date Contents

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5Social care

246.Covid-19 has been a particular scourge of the elderly. Before vaccination, all the charts that laid out the susceptibility of people to death from Covid were brutally clear: people aged 80 and older who contracted covid were 70 times more likely to die than people aged 40 or younger.377 This meant that the arrangements to protect the elderly were of vast importance, especially during the early stages of the pandemic when no vaccines were available to protect such vulnerable people.

247.For these reasons, the experience of the social care sector has been pivotal to the pandemic. More than 70% of new requests for social care support are from older people.378 The settings in which social care is provided—such as communal homes in which elderly people live, cared for by workers coming into their home from outside, and which normally welcome a continuous stream of visitors—are obviously particularly susceptible to the spread of a virus like covid-19 transmitted by human-to-human contact.

248.Our inquiry took evidence from the loved ones of people living in care homes and being cared for at home, people who work in the sector, as well as policymakers and Ministers. The experience of the sector during covid is one of intense stress, with some decisions made which caused the experience of residents and their carers to be more difficult and which, sadly, are likely to have resulted in more deaths than was inevitable.

Impact of the pandemic in social care

249.Between 16 March 2020 and 30 April 2021, 41,675 care home residents died of covid-19—nearly a quarter of deaths from all causes among care home residents.379 This amounts to over a quarter of all covid deaths in England over the same period of the pandemic. This is likely to be an underestimate given the lack of testing of care home residents during the early weeks of the pandemic.

250.The number of deaths of people receiving domiciliary care between 10 April and 19 June 2020, meanwhile, was over 120% higher than the three-year average over the same period between 2017 and 2019, with 12.6% of the total involving a confirmed case of covid-19.380

251.The UK was not alone in suffering significant loss of life in care homes, but the tragic scale of loss was among the worst in Europe and could have been mitigated.381

252.The impact of the pandemic on the social care workforce has also been acute. Between March 2020 and August 2020 7.5% of workdays were lost to sickness absence compared to 2.7% before the pandemic.382 During the first peak of the pandemic, between March and May 2020, the Office for National Statistics recorded 760 deaths of people working in care, nearly twice the average during the same period from 2014 to 2019. During the course of the pandemic 74% of deaths recorded for social care workers had covid-19 recorded as a cause of death.383

253.The Government responded to the crisis experienced in social care during the first wave on several fronts, which appears to have partly reduced the disproportionate impact of covid-19 on care homes during the second wave of the pandemic. Analysis shows that between 31 October 2020 and 5 February 2021, 26% of the total number of all covid-19 deaths occurred among care home residents, compared to 40% during the first wave of the pandemic between mid-March and mid-June 2020.384

254.Although by early September 2021 95% of older adult care home residents (aged 65 or over) and over 80% of care home staff had now received two doses of a covid-19 vaccine, the proportion of staff who have received two vaccinations is significantly lower than the rate for residents and varies by region. The fact that many social care staff still remain unvaccinated will present a major challenge for the sector going into the winter.

‘Protect the NHS’

255.Witnesses to our inquiry suggested that the Government’s emphasis on “protecting the NHS” first and foremost caused specific practical problems for social care providers. As Professor David Oliver, a consultant geriatrician and Nuffield Trust fellow put it: “Protect the NHS essentially meant protect the acute hospital bed base, with everything else a bit of an afterthought. That was a mistake.”385 This was echoed by other witnesses to the inquiry including Philip Scott, a family carer whose mother is a care home resident. He described feeling that care homes were “very much sidelined” during the first part of the pandemic.386

256.Some witnesses suggested there was insufficient alertness to the risks presented by covid-19 to the sector. Jane Townson, Chief Executive of the UK Homecare Association, stated that “knowledge of home care and social care more widely in the Department of Health is quite weak”.387 This was echoed by Professor David Oliver who referred to his own time working in the then Department of Health (as National Clinical Director for Older People from 2009 to 2013) and suggested the level of expertise has declined.388

257.The then Minister for Care, Helen Whately MP, acknowledged a disparity in weight within the Department in her evidence to us:

[We] are talking about a hugely diverse sector, which does not have the type of infrastructure that we have for the NHS. For the NHS, we have NHS England. […] In the Department we have a social care team that, initially, was purposed to look primarily at social care reform. We have built up those resources. We have built up the infrastructure that we have. All the time, we have been doing a balance in wanting to get guidance and support out quickly to the sector while wanting to engage with the wide range of forms of care that we have.389

258.In its response to the Health and Social Care Committee’s Report, Social care: funding and workforce, the Government set out some of the steps it had taken to support social care during the pandemic and beyond. For example, in December 2020 a Chief Nurse for Adult Social Care was appointed to provide leadership to the sector and within the Department, and in June 2020 the Government established the social care taskforce for the covid-19 response, which produced several recommendations for managing covid-19 across different social care settings.390

259.Nonetheless, the lack of priority that witnesses said was ascribed to social care during the initial phase of the pandemic was illustrative of a broader and longer-standing issue in the health and social care system. The fact that there is more progress that needs to be made was acknowledged by the then Secretary of State who described “parity of esteem” between the NHS and social care as “a goal that we should seek” and by Sir Simon Stevens, then Chief Executive of NHS England, who called for health and social care to be seen “as two sides of the same coin”.391

Discharge of patients to care homes during the first wave

260.The most damaging way in which the prioritisation of the NHS over social care manifested itself during the first wave of the pandemic was in the rapid discharge of people from hospital to care homes without adequate testing. In order to free acute hospital beds in anticipation of the first wave of the pandemic, NHS providers were instructed to urgently discharge all medically fit patients as soon as it was clinically safe to do so, and care home residents were not tested on their discharge from hospital.392 Around 25,000 people were discharged from hospitals into care homes between 17 March and 15 April 2020, and while the total number is smaller than in the preceding year due to significantly lower admissions, during the critical weeks in early March there was a marked increase in the number of discharges to care homes compared to the previous year.393

261.Given the scenes that were emerging in hospitals in other parts of the world, it was essential for the NHS to take immediate steps to increase its acute capacity. It was also important to ensure that people, especially those who were at high-risk, were not being put at unnecessary risk of contracting covid-19 by being in hospital any longer than they needed to be. Ultimately, moving as much care as possible into the community and discharging people from hospital as soon as they are medically fit is an agreed direction of travel more generally in the health service. As Professor Oliver put it:

In general, in peacetime and before the pandemic, you do not want people marooned in hospital beds who are fit to leave hospital. We have had far too many delayed transfers of care, so in some respects having emergency legislation and funding to say that if people do not need to be there we should move them on was a good thing.394

262.Nonetheless, examples from other countries showed what a more effective discharge policy could have looked like. Isabell Halletz, Chief Executive Officer of the German Care Home Employers’ Association said in May 2020:

[The discharge of patients from hospitals to care homes] was a very hot topic in discussions with the Federal Ministry of Health and the local health authorities […] we saw a very big risk for residents living in long-term care from patients coming from hospitals and from new residents who had not been in the home before. They have either to provide a negative test result or to make sure that people coming from hospitals stay in quarantine for 14 days.395

Infection prevention and control

263.However, there were several factors during the early period of the pandemic which meant that it was not possible to safely discharge patients to care homes and at the same time avoid outbreaks of covid-19 within those homes. Most obviously, a lack of testing capacity meant that patients were not prioritised for testing ahead of being discharged to care homes. We received differing evidence on whether the decision to discharge patients to care homes was taken in the full knowledge that there was not sufficient testing available for them. Dominic Cummings told the Committee that he and the Prime Minister were briefed that patients would be tested:

As I said before, we were told that the people were going to be tested. We obviously discussed the risk. We were thinking, “Hang on—this sounds really dangerous. Are we sure?” There was a kind of, well, there is no alternative. Because the whole original plan had gone so badly wrong, the view was, we have got to try and free up beds in the NHS to deal with the wave that was coming. So the view was there is no alternative, but secondly, we were assured that the people who were being sent out would be tested.396

The then Secretary of State for Health and Social Care confirmed that this policy had been “agreed at the highest level in Government” but told us he could not specifically recall what advice was given regarding testing at this point. However, he did note that testing capacity was only around 1,000 tests per day at the time of the policy being agreed, and stated:

There is no doubt that the testing capacity would have featured, but also remember that the clear clinical advice at the time was that testing people asymptomatically might lead to false negatives, and therefore was not advised and was seen as not a good use of the precious few tests that we had at that moment.397

264.In practice there was no expectation that patients should be tested as a precondition to discharge. The Government’s first set of guidance, issued on 19 March 2020, included no reference to covid-19 testing except to state that “where applicable” covid-19 test results should be included in a patient’s discharge documents.398 Guidance issued subsequently on 2 April 2020 reiterated that “negative tests are not required prior to transfers / admissions into the care home.”399

265.The Government has subsequently claimed that the discharge of patients to social care did not seed significant numbers of covid-19 outbreaks in care homes. Referring to a report commissioned by the Government from Public Health England, which claimed that only 1.6% of care home outbreaks could be linked to hospital discharges, the then Secretary of State stated:

The evidence has shown that the strongest route of the virus into care homes, unfortunately, is community transmission, so it was staff testing that was the most important thing for keeping people safe in care homes.400

266.However, given the acknowledged unavailability of adequate testing of care home residents during the early period of the pandemic, it is likely that the report, which analysed 43,398 test-confirmed cases of covid-19 among care home residents (between 30 January and 12 October 2020), is based on an underestimate of the true number of cases during this period. The then Secretary of State defended this estimate but nonetheless acknowledged its limitations, stating:

It is a difficult figure to put a number on […] It is always a challenge to measure these things—and estimates are estimates. I think I described it as an estimate rather than a fact partly for this reason.401

The Department of Health and Social Care subsequently confirmed that this paper was reviewed by members of the SAGE social care working group, as well as going through internal quality assurance.402

267.Guidance on testing was issued on the basis that care homes would be able to safely isolate people who were admitted from hospital. However, in reality many care homes lacked the facilities to safely isolate patients admitted from hospital. At the most basic level not every care home had the physical space to be able to effectively isolate patients being discharged from hospital. Vic Rayner, Executive Director of the National Care Forum highlighted this issue: “The majority of our care home stock is 20 to 30 years old, if not older in some cases. They are buildings that were set up for people to come together and share space”.403 Similarly, Professor Martin Green, Chief Executive of Care England, explained:

We should acknowledge that there are lots of care homes, as you say, that are, in effect, at the end of their shelf life, and there needs to be a big investment strategy. We have to look at that in terms of the future, but it would have been great to have had some kind of database that identified the care homes that had the capacity to do more isolation and the ones that did not.404

268.The risk in care homes was further compounded by poor access to PPE during the early period of the pandemic. In March 2020, Sarah Pickup of the Local Government Association called access to PPE “insufficient” and James Bullion of ADASS called the delivery of PPE “extremely erratic and difficult,” while by May 2020 Professor Martin Green stated that “even now, we are still in a position where people are not getting enough PPE.”405 The Government took action to address these shortages including adding CQC-registered social care providers to the Government’s PPE supply chain and providing free PPE via personal Local Resilience Forums for other types of care provider.406

269.Finally, efforts to carry out effective infection control in social care settings were undermined by workforce factors, including both pre-existing shortages and shortages due to covid-19, as well as a lack of access to asymptomatic staff testing. The movement of care home staff between different homes has been a particular area of focus, with the ONS’s Vivaldi study of 9,081 care homes for older people (aged 65 and over) finding that care homes that regularly used bank or agency staff, or homes where employed staff regularly worked elsewhere, had higher risk of infection.407 The study also “found that the payment of sick pay was associated with a decreased risk of covid-19 infections.408

270.James Bullion of ADASS suggested that the reliance of social care providers on agency staff reflected longstanding staffing difficulties in the social care workforce:

We have a 35% turnover rate and social care staff without a career grade structure.

The fact that we have agency staff moving between three or four different establishments is a consequence of the structural model we have. We need to look at a salaried model based on outcomes and higher levels of wages.409

Indeed, almost a quarter of social care staff, and 34% of care workers, are on zero-hours contracts. There are an estimated 1.09 jobs per person across all parts of the social care sector, while the proportion of care workers working part time is 51%, suggesting that a high number of care workers hold second jobs.410

271.These workforce factors were compounded by the impact of staff absences due to covid-19, and the lack of access to asymptomatic testing for social care staff. As has already been noted, between March 2020 and August 2020 staff sickness absence was three times its rate before the pandemic. An already-high vacancy rate (estimated to be 7.3% in 2019–20 equivalent to 112,000 roles) was compounded by sickness absence due to covid-19, undermining the ability of remaining staff to effectively do their jobs.411 For staff with no symptoms of coronavirus, regular testing was not announced until 28 April 2020, while the Health and Social Care Committee’s Report, Social Care: funding and workforce, found that the roll-out of regular testing continued to be challenged until well after the initial peak of the first wave of covid-19, thus increasing the likelihood of care workers unknowingly attending their workplaces with covid-19.412

272.The result of these factors was that the initial risk created by the lack of available testing for patients on discharge was compounded significantly by a lack of space in some care homes to carry out effective isolation, shortages of vital PPE, and staff factors which made preventing onward transmission by social care staff challenging. Both the Government and the NHS were slow to recognise this. Professor Martin Green told the Health and Social Care Committee in May 2020 that guidance was “not really connected to the reality of lots of care homes” and was issued “for the perfect world” rather than the one we are in.413 Professor David Oliver highlighted that this lack of awareness had also been an issue for the NHS:

There was not enough testing. There was not enough PPE in care homes or outside the PPE supply chain. Acute healthcare did not fully appreciate the limitations of trying to do infection control in care homes. Let’s face it, if we had a norovirus outbreak, a clostridium outbreak or a flu outbreak on a hospital ward that we can test for, we would not decant all of those people into care homes.414

273.Dominic Cummings recalled that there had been serious failings in the Government’s handling of the pandemic in social care. In particular, he acknowledged that the risks to social care were not properly identified:

It was not thought through properly. There wasn’t any kind of proper plan. It is clear in retrospect that a completely catastrophic situation happened, with people being sent back untested and then seeding it in care homes. There is no other way to describe it than that.415

When asked about the level of protection offered to care homes early in the pandemic, the then Secretary of State for Health and Social Care stated:

We knew from the start, from very early in January, that the impact of this disease was most significant on the oldest, and therefore care home residents were going to be a particular risk […] We set out guidance for care homes. The first guidance was on 25 February.416

However, while this initial guidance to social, community and residential care settings included advice on respiratory and hand hygiene, it ultimately stated:

Currently there is no evidence of transmission of COVID-19 in the United Kingdom. There is no need to do anything differently in any care setting at present.417

This guidance was withdrawn on 13 March 2020 and replaced by new guidance covering hand hygiene, visiting policy, PPE and staff sickness in more detail.418

274.International best practice further highlights the lack of pandemic preparedness in social care. Professor Terry Lum, Professor of Social Work and Social Administration at Hong Kong University described how care homes in Hong Kong learnt from the experience of SARS. As well as highlighting the importance of “[stopping] the transmission from hospital to nursing home” and isolating infected people, Professor Lum stated:

After the SARS outbreak, we found that we needed someone in the nursing home to co-ordinate all the infectious disease control. The Government require that all nursing homes have one person, usually a nurse, trained as a professional to handle infection control. […] nursing home operators have a kind of annual fire drill for infectious disease control […] That drill, year after year, has become a kind of practice. It is extremely well practised in nursing homes.419

However the UK Infection Prevention Society stated that “there are scant resources to support [infection prevention and control] in the care home sector across the UK” and further that:

The regulation of IPC in care homes is poor, it is not perceived as an integral part of quality and inconsistently and inappropriately monitored […] The level of qualified IPC support to care homes on a national level is minimal and such services have been under resourced for many years. In some areas the qualified IPC support can be as little as one Infection Control Nurse for 300 care homes.420

Visits in residential care settings

275.Visits to residents of care homes were subject to severe restrictions for much of the first phase of the pandemic, causing great strain for residents and their family and friends. Philip Scott, who was largely unable to visit his mother during the first wave of the pandemic, told us:

It is great that the home has been facilitating Skype and, in the summer, introducing garden visits, but it is not the same as actually being able to see her, hug her or hold her hand. During March and April [2020], when the virus was ripping through care homes, it was a time of considerable anxiety for both myself and my sister.421

276.James O’Rourke described the difficulties his family faced visiting his brother, who has learning disabilities and lives alone in a supported living flat:

The first lockdown was incredibly frustrating but understandable, given that we did not understand what the virus was about. The guidance was scant. […] The second lockdown, for us as a family, was horrendous. I need to put in some context. Tony lives in a one-bedroomed flat […] but the care provider treated it like a residential care home and completely locked it down, not giving us any access to Tony whatsoever.422

277.Care providers who gave evidence to the inquiry expressed a desire to enable visiting but highlighted the lack of resources and guidance to be able to do so. Theresa Steed, a care home manager, welcomed the suggestion of lateral flow test-enabled visiting, but highlighted uncertainty around the use of those tests.423 Similarly, Steve Scown of Dimensions UK, a charity care provider, highlighted the delay in Government-issued guidance to supported living providers.424

278.In October 2020, the then Minister for Care announced trials of regular visiting by named individuals enabled by PPE and regular testing, and in the following month the then Secretary of State announced the intention for indoor visiting by Christmas, followed by new guidance on 1 December which made provision for indoor visits facilitated by PPE and rapid testing.425

279.New guidance issued by the Government from 8 March 2021, and subsequently extended from 17 May, provided not only for the return of indoor visits for named visitors, but also enabled residents to nominate an essential care giver. From 21 June 2021, this has been extended to allow residents to nominate up to five named visitors, of which two can visit at one time.426 This is welcome progress, but it should be noted that the costs associated with enabling safe visiting will continue even despite continued progress against covid-19, and the infection control fund for social care providers is scheduled to end on 30 September 2021.427

Underlying challenges facing the care sector

280.The pandemic occurred against a backdrop of issues in social care including workforce shortages, funding pressures and provider instability which successive governments have failed to address. Even without the factors explored above, these long-term issues meant that the sector entered the pandemic in a weakened state which hampered its ability to respond to the impact of covid. Jane Townson described home care as “[coming] into the pandemic with low status and in a weakened condition”, the Local Government Association described adult social care services as being at “breaking point” prior to the pandemic, while Care England stated that “the adult social care sector was not in as good a shape as it could have been due to the long term neglect of the sector”.428

281.Despite these lasting issues, the Health and Social Care Committee’s Report on the Government’s White Paper proposals for the reform of Health and Social Care noted a lack of concrete proposals for the long-term reform of social care in either the Government’s White Paper or the subsequent Queen’s Speech, and concluded that “without secure, long-term funding, the problems that have bedevilled the care sector over the last two decades will not be solved.”429

The social care workforce

282.As noted above, the social care workforce entered the pandemic in a weakened state. In 2019–20, there was an estimated vacancy rate of 7.3% across the year, equating to 112,000 vacant roles. The turnover rate was 30.4%, and around a quarter of the workforce (24%) were employed on a zero-hours contract. While pay has increased since the introduction of the National Living Wage, care workers continue to be low paid, with the average pay of retail assistants and cleaners having overtaken care workers in 2019–20.430 The Health and Social Care Committee’s Report on social care found that:

[Low pay] devalues social care workers who are often highly skilled; is a factor in high turnover rates and high numbers of vacancies; and as a result undermines the quality and long-term sustainability of social care.431

283.The Health and Social Care Committee’s Report, Social care: funding and workforce, also identified training and career development as a particular issue for social care workers.432 This had specific implications for the ability of the sector to respond to the pandemic: the University of Kent reported that a third of respondents to their survey had no training in infection control or in the proper use of PPE.433 This was echoed by the UK Infection Prevention Society, who described care homes as being “expected to be able to successfully prevent and manage outbreaks of a respiratory virus with little or no training and support.”434

284.The Health and Social Care Committee’s Report, Workforce burnout and resilience in the NHS and social care, further highlighted the absence of detailed workforce planning in the social care sector, concluding in particular that the lack of an equivalent People Plan for social care “serves only to widen the disparity in recognition and support for the social care components of health and social care.”435

Funding pressures

285.Professor David Oliver described how the pandemic had highlighted long-standing funding pressures:

There were underlying structural problems in the funding and staffing of social care, both in care homes and in people’s own homes, before the pandemic. But, before, they were invisible. Even the care homes were invisible. Now at least we have them in the spotlight.436

286.Jane Townson pointed out that home care providers were still incurring significant PPE costs due to the need to provide PPE above and beyond the level provided for free.437 Similarly, social care providers have faced increased insurance costs due to the risks of outbreaks, with Care England suggesting that this has been a particular barrier to care homes acting as designated sites for isolating patients discharged with covid-19.438

287.The Government’s response to the Health and Social Care Committee’s Report on social care outlined the steps it had taken to address the short-term funding pressures placed on social care providers including through the provision of free PPE, the Infection Control Fund (worth £1.1bn) and the new state-backed indemnity fund for designated isolation settings. However, the Government has not yet brought forward a long-term funding solution for social care.439 Moreover, evidence to our inquiry also highlighted the potential for the impact of the pandemic to compound these long-term funding pressures, with significantly reduced occupancy rates in social care potentially threatening sustainability in the medium-term.440

Conclusions and recommendations

Conclusions

288.The covid-19 pandemic has put massive strain on a social care sector already under huge pressure, which has a particular focus on caring for elderly people who have been at the greatest risk of death from covid.

289.Social care had a less prominent voice in Government during the early stages of the pandemic than did the NHS.

290.The discharge of elderly people from NHS hospitals into care homes without having been tested at the beginning of the pandemic—while understandable as the NHS prepared to accept a surge of covid patients—had the unintended consequence of contributing to the spread of infection in care homes. The seeding of infections also happened as a result of staff entering care homes, and the failure to recognise this risk early is a symptom of the inadequate initial focus on social care. The lack of available testing at the time meant that the extent of spread by each route of transmission cannot be fully known and has not been conclusively determined by the report commissioned from PHE by the Government.

291.Staff shortages, the lack of testing, difficulties in obtaining PPE and the design of care settings to enable communal living hampered isolation and infection control and the ability to keep covid at bay. Social care staff in care homes and providing domiciliary care worked under strenuous conditions, at risk to themselves, to provide care to people.

292.Many of these pressures on the social care sector—such as funding and workforce—are longstanding and must be resolved urgently. Pressures on the social care workforce are likely to be compounded this autumn by the mandate that people working in the social care sector must be fully vaccinated to continue to provide care in residential care homes.

Recommendations and lessons learned

293.Planning for future pandemics should have a more developed and explicit consideration of the intense interaction between the NHS and social care. The prominence of social care within the Department of Health and Social Care should be enhanced and Ministers must address the relative lack of knowledge and experience of social care within the Department and senior levels of the NHS. The Department should ensure that future policy and guidance relating to the sector is well-informed and reflects the diversity of the sector. The Department must also set out how it plans to retain the expertise of the Social Care Taskforce on a more permanent basis.

294.Long term reform of social care is overdue and should be pursued as a matter of urgency. The Government’s recent announcement on the future of social care is welcome, but the long-term future of the sector remains unresolved. We endorse the Health and Social Care Committee’s call for a 10 Year Plan for Social Care to accompany the 10 Year Plan for the NHS. It must ensure that there is parity between the health and care sectors so that social care is given proper priority in a future crisis.

295.We endorse the Health and Social Care Committee’s call for additional resources to be directed to social care. That Committee has made the case for an increase of £7 billion a year by 2023/4. We note that despite the Government’s recent announcement the level of new investment in social care from 2023/24 remains unclear.

296.The Government should review the provision of infection prevention and control measures, including infection prevention and control nurses, to social care and ensure that social care providers, particularly care homes, are able to conduct regular pandemic preparedness drills. The Government must ensure that care homes have isolation facilities and social care providers are able to provide safe visiting for family and friends of care home residents.