Covid-19: The support UK care homes need to survive

Clinical and bereavement support

Care homes need input from clinicians to help them through this crisis; NHS England’s Enhanced Health in Care Homes framework gives some indication as to what this should look like.11 The model was piloted in 2016 and is now a requirement of the 2020-21 primary care contract. It emphasises the importance of care homes having access to a named GP, who is linked to a wider community health team.12

Maggie Keeble, a GP for five care homes with 160 residents in Worcestershire, is driving forward this approach as part of her area’s response to the pandemic.

“I’ve been working really hard this week on a combined integrated response, so that we’ve got a medic and a district nurse in each area who is a go-to person for care homes and that these people are talking to each other as well,” she says.

Keeble, who is also clinical lead for care homes at the Herefordshire and Worcestershire Clinical Commissioning Group (CCG), has one nursing and four residential homes in her care, one of which currently has residents who have tested positive for covid-19.

She says the CCG acted quickly to get iPads into every care home, ready to enable video consultation with GPs. She’s also set up a Zoom call for all care homes in the county, which has already risen from four participants to 27.

“We’re also looking at how we can provide bereavement support for care home staff, because I’m very conscious that’s going to be a big area too,” she says.

“The chaplains network in Worcester has offered to do an online combined memorial service for staff, or one for each individual home, if they would like that.”

Isolation arrangements

Where a home does have a suspected or confirmed case, they must isolate the resident. The International Long term Care Policy Network has published a strategy for how a building could be divided into risk zones.13 Residents are put into a green, amber, or red zone, depending on whether they have no symptoms, have no symptoms but recently returned from hospital, or are displaying symptoms.

An extra challenge for staff will be isolating people with dementia, whose condition may mean they walk with purpose around the home, and those who may lack the capacity to understand why they need to be isolated and to consent to it.

Aswini Weereratne, a barrister at Doughty Street Chambers in London, tells The BMJ that any decision to isolate residents in these circumstances “must always be taken in the person’s best interests by their carers,” following the process outlined in the Mental Capacity Act. The DHSC has confirmed there is no change to this requirement.14

“If isolation will lead to a new deprivation of liberty or add restrictions to their care which they did not have before, then the law requires there to be an assessment for a deprivation of liberty safeguard under the Mental Capacity Act,” she says.

The key, Weereratne says, is if there is a real risk to life that engages article 2 of the European Convention on Human Rights, “which there must be in congregated settings like care homes,” she says. In this instance, a person may need to be moved out of the home temporarily or cared for on a one-to-one basis, for example with the help of family.

Care staff will often be the best placed to come up with practical solutions for residents who walk with purpose, says Adam Gordon, professor of the care of older people at the University of Nottingham, as they will know them well. He says one example he has seen is staff using mobile partitions to section off a corridor, so the person could still move freely around a part of the home.

“There are also a number of areas that have set up arrangements where care home staff can access dementia specialist nurses, who are able to give advice on pharmacological management to support the staff,” he says.

Rapid access to drugs

One issue that had not been updated by NHS England and the DHSC until recently was access to palliative care drugs. Existing law prevents care homes from keeping a stock of the drugs, and they must be supplied on a resident by resident basis.15

Keeble says GPs had been asking for direction from NHS leaders “for weeks” but were told to “get on and create local policies,” which she says is “unforgivable.”

On 28 April the DHSC and NHS England published a standard operating procedure for a medicines reuse scheme in care homes.16 This will allow health professionals to reuse a medicine that is no longer needed by the person it was originally prescribed for, providing the criteria set out in the guidance are fully met.

Keeble and Gordon welcome this as a significant move forward. But Gordon adds that, while it is a step in the right direction, it’s not a complete fix because it still does not allow care homes to keep a stock of palliative care drugs. He says this is needed so medical staff can provide “much more responsive” care.

“A number of care home residents often have quite complex palliative care requirements, but the end of life experience with covid-19 is quite a lot more distressing than say a standard community acquired pneumonia,” he says.

“This means care home staff have to be able to access palliative care expertise, and most importantly it means they need rapid access to palliative care drugs.”

As the country moves into its 20th week of the pandemic, Keeble says GPs and community health teams need to know who their care homes are, make contact with them, and make sure they’ve got access to technology in one way or another.

“The irony is there was lots of modelling in the early days and a massive focus on hospitals; but as ever, everyone just took their eye off care homes,” she says.

“The lesson must be learnt that we have a lot of people in care homes, and we have as many staff caring as we do in the NHS—they are as vulnerable, they are as much on the front line, and they have been neglected for years.”

Back at Broomgrove Trust in Sheffield, Pierpoint is feeling the burden of this neglect: “There’s a long way to go, there isn’t light at the end of the tunnel yet. We’ve still got to keep going, we can’t take our finger off the pulse.

“I’m still scared that we may well get it. I just hope that we continue now to get the support, that the PPE does ramp up, and that we can get on top of this as a nation.”