- David Oliver, consultant in geriatrics and internal medicine
Follow David on Twitter: @mancunianmedic
From the time the first recorded case in the UK until June 5th, the Office of National Statistics (ONS) reported 17,422 deaths of residents of a nursing home aged 19 in England and Wales – 47% of the total.
British Health Secretary Matt Hancock insisted in the media that only about 30% of deaths in England were in nursing homes, saying that it was lower than the European average using data from the Department of Health and Welfare based only on people who had a positive result on covid-19 (when the tests were not enough), and not on a death certificate – the approach used by ministers throughout the pandemic.
Although the ONS began to publish data on mortality in all conditions and the excess of all causes of death on March 13, it was recorded on March 13, but there was a delay before they were included in the daily briefings on Downing Street.
Daily data on the number of deaths at briefings was supplemented by personal reports of families of the victims who could not be with their loved ones when they died. Home care managers and staff said they were overworked, ill themselves and that they did not have adequate access to personal protective equipment or testing.
The media reported less often that residents of nursing homes are generally weak and live in the last or two years of their lives and are prone to any outbreak of the respiratory virus, with about a third of all residents dying every year.45 In addition, mortality rates in nursing homes can indeed be very low if instead all residents die in hospital wards.
Media reports have barely addressed concerted efforts over the years to ensure that residents of nursing homes can be supported there when they are sick or dying, and not delivered to busy, alienating hospitals; or a growing problem facing a pandemic of people who need to be transferred to nursing homes and hospitalized, sometimes for several weeks.67 Even before the pandemic, we in the health and social welfare sector have repeatedly emphasized the crisis in home care, staffing financing, financial viability and inconsistent support from overloaded local NHS services that lacked the resources to operate, and the press showed a passing interest.
The media story of deaths in nursing homes in the 19th year became one of the brutal bureaucrats, politicians and managers ruthlessly throwing residents of nursing homes to preventable deaths, deliberately sacrificing residents to “protect” sharp hospital beds. Supposedly, hospitals intentionally sent residents back to nursing homes without covid-19 tests or even after positive results. 8 A new analysis of the data shows that hospital discharge back to nursing homes increased from year to year over a critical period of March 9, despite Statements from the government and NHS providers who write numbers from the hospital to nursing homes in March and April were much lower than in previous years.
Prior to receiving any guidance from NHS England, emergency laws, or government cash infusions, 12 emergency hospitals across the country were engaged in escalation plans to prevent swamping of hospitals. In part, this was aimed at strengthening outpatient emergency care, the rapid delivery of inpatients to their homes (or nursing homes or public hospitals), as well as close collaboration with public health services to increase support and acceleration.
These are not NHS politicians, officials, and managers who accept or discharge hospital patients, but doctors who work with multidisciplinary clinical teams. Obviously, many of us – in good faith and for obvious reasons in this early pandemic situation – sent people to nursing homes with or without testing on criteria 19. We are also responsible and should not try to divert all the blame.
But remember that in March and early April, even in hospitals with an acute course, they tried their best to get the covid-19 test for our own patients or staff, the processing time was often days, and now we know that the first tests are negative in about one of three cases where people continue to give a positive result. The relationship between a positive or negative test result and its infection for others or the duration of the “safe” quarantine period is not clear13. Indeed, someone can give a negative result, leave the hospital, and then in a few days get a positive result in the care home. A resident of a nursing home, stuck in a hospital, could have avoided covid-19 by being there.
The road is not taken
A recent study by the London School of Economics showed that not all outbreaks in nursing homes were from hospital relocations, with staff being carriers, especially agency staff working in different institutions, and staff often walked between residents’ rooms to help. +0.14
But let’s just imagine the opposite: the road is not taken. How would people react if a large number of acute beds in a country with one of the lowest (and most complete) per capita bases in the Western world 15 were occupied for several weeks by residents with medical care away from their homes? Families and familiar staff? And despite media reports from the patient care sector about the difficulties that NHS teams have faced with examining or delivering patients to the hospital, I have yet to see reliable data on residents who died from illness 19 or other causes that were would be rescued by urgent inpatient treatment and he was denied.
I believe that some of the now clearly erroneous decisions in local nursing home services have been made in good faith, in new and urgent situations – and yes, in many European countries there has been a similar mortality rate in nursing homes according to covid-19. Neither a defensive denial of events in sight, nor a game of guilt will help. What is important at the moment is how we can act differently to protect the residents of the nursing home if we have a second wave or a new pandemic – something that I will discuss next week.