Care homes crisis, the British state, and the perils of over-centralisation

As autumn drifts into winter and the number of coronavirus case escalates, focus turns to the plight of the elderly – the many isolated and infirm at home, and the more than 400,000 in care homes. A recent investigation from Amnesty has highlighted the UK’s failures in this area during the first wave of the virus.

Meanwhile, reports from the ground suggest that larger care homes have struggled the most in responding to the crisis, while inflexible and ineffective public sector strategies have often compounded the problems faced by hard-working staff and family members.

The care homes crisis experienced earlier in the year has revealed the deep flaws in how power and decision-making is structured in Britain. Longer term, the UK must get better at decentralising authority and providing real scope for local initiative to avoid further catastrophe over the coming months.

Yet Britain is not alone in experiencing these problems, and in order to improve the national strategy as the country moves into the winter, the UK can learn from what has failed and what has worked elsewhere.

The need for urgent implementation of a new strategy, locally and centrally, is stressed in the short and forthright special report on Covid-19 by the Royal Commission into the Care Sector published by the Australian government last Thursday. The UK Government needs to learn from this, adapt and improvise from it, and implement in short order.

One of the most striking Australian proposals – with huge resonance for England – is that each care home, private or public authority should have in residence, or on call at least, a fully trained infection control officer, and this would be a condition for a home’s license and accreditation.

In England some local health authorities, and local government bodies have reacted pretty vigorously to the emergency – offering professional and voluntary help for anything from clearing loos and garbage, to supplying food and protective PPE. Jeremy Hunt, former Health Secretary and now Chair of the Commons Health and Social Care Committee, thinks devolving management to the local and regional level is the only way of salvaging the chaotic test and trace programme.

The government did try to throw money at the elderly care sector as it unraveled. In March £1.6 billion extra was given to local government in general for the emergency – with £500 million in mid-May for testing in care homes themselves – two months after the emergency had broken. Last month it tried again, and awarded a further £546 million for care homes “to reduce coronavirus spreading in the winter.”

On the ground, where does this all go, and how does it work out? The answer to that is complex and indicates that, among major problems faced by the sector, there are structural as well as financial problems at play.

I talked to three people with direct involvement in caring for the elderly, a trustee for a charity with an elderly parent in residential care, a volunteer manager and coordinator, and a charity chair who volunteers for helping the elderly in their homes and in a large care home. They have been working or have direct experience in the North West, the North East, the Home Counties and the South.

The overall impression they give is of muddle and eye-watering neglect, of good intentions and hard work by many, and staggering lack of application, vision and strategy by government, local and national.

Kate Holt, is a well-established writer and journalist, and is trustee to an effective charity for voluntary, tough disaster rescue work. Her elderly mother, 85, has been suffering from Alzheimer’s for three years. The old lady was in a care home in Cumbria when lockdown came in March. And it arrived with a vengeance.

“They were more or less confined to their rooms. We couldn’t visit, of course, though we did manage to wave through the window once. They were overwhelmed in that home, and four died of Covid in the first weeks.

“Isolated in her room, my mother didn’t move. She needs assistance in walking. She had nearly four weeks without walking. When we saw her, there had been massive deterioration, her muscles had diminished, she was dehydrated and had bad pressure sores. Activities had stopped, they couldn’t go outside. The will to live declined.

“They just didn’t have enough staff. There were 102 in that home, but by the end of the first wave of the crisis, there were only 75.”

Kate had returned from Washington, where her husband is posted. She took her mother away from the home, and looked after her in her own Cumbrian house, and subsequently has placed her in a smaller care home. “The bigger homes have really struggled,” she told me. “The patients and residents tend to become just numbers.

“We paid £1400 a week for her care, and you expect some level of professional standard. She was entitled to a quality of care that she just didn’t get.” There were no visits from a GP when they were needed and the Care Quality Commission – England’s independent regulator for social care services – kept away. “Mum came out very dehydrated, covered with pressure sores. The GP could not get out to see her – would not get out to see her.”

Kate also worries about the blanket use of the DNAR – do not resuscitate notes – on files. She is also concerned that the way the authorities in and around the Lake District sold off the smaller cottage hospitals – “they went for holiday flats and second homes.” Today they are of exactly the right scale and intimacy for residential care homes. Instead Cumbria, is building a “custom made” care hospital for 140 residents.

Laura P, is a volunteer coordinator for the same charity. She is a highly experienced international disaster coordinator and rescuer, running help for whole districts in the worst of the recent Mozambique floods. She has a successful business for festive decorations; and it too is proving of a doughty survivor even in the Covid-ridden North East.

Focusing on Middlesbrough and Teesside, now facing renewed lockdown, she paints a complex and disturbing picture. “The main issue is information on the ground, clear information. Local charities have been working, and they have been helped by the Local Resilience Forum – LRF. The LRF was supposed to be the focus for local coordination under the government’s civil contingency plans for emergencies. They haven’t been a universal success, and are often bypassed.

“One of the biggest worries now is for flu vaccinations,” says Laura. “The GPs need public venues to carry this out. The problem is that the charities are cutting back, they’re running out of funds so can’t rent the kind of spaces they did before – and are now operating from remote buildings like warehouses on the edge of town.

“The NHS responder scheme, too, is problematic. Initially, they couldn’t place or use the volunteers that first came forward. Now the volunteers aren’t available. Furlough is ending, and people have to go on to other things. They are not going to volunteer again.

“Phones are another problem. The NHS apps work through the internet. But in Middlesbrough 70% of homes don’t have internet. Most homes on Teesside don’t have a computer. So how can they link up?

“Demands now at food banks are low for the time being, though requests for food parcels in homes are rising.”

She says that the small charity sector is now contracting rapidly, perhaps when it is about to be needed most. “They have used up their £10k and £25k grants, and they are downsizing. They share intelligence through bulletin blogs and newsletters, but many won’t survive at all.”

Nick P, is the former chair and founder and is now senior patron of the charity for which Kate and Laura volunteer and help. After a distinguished public career at the highest level, he still volunteers to help with care homes. Recently he has been helping at a large care home in the Home Counties, which I won’t name for legal reasons. After a battering from Covid, including deaths, staff sickness and absenteeism, the home is still coming up for air.

“We went to help tidy up, clean the floors and put things straight.” At one home this summer, Nick and his team had to unblock the loos and clear human waste from the garden.

“We helped put the furniture straight in the day rooms and clear the corridors. The effect on the staff was remarkable. They were so grateful, not just that we had helped them, but that we cared. They had suffered very badly from the months of Covid. Mental health, as much as under manning, training, poor pay and lack of PPE is one of the major problems for the care sector.”

He says, with not total conviction, that he hopes the government is aware of this. “The problem is that everything is over-centralised. And we have a government that is obsessed with data. Gathered in and analysed at the centre, they think it is the means to solving everything.”

This not the time for enquiry. The exercise proposed by Amnesty might be a self-indulgence too far at the present stage of the crisis. A clear strategy, plan of action, message and public engagement needs to be led from the centre. But real power, ability to take the initiative to give help must be handled and decided locally, as the three witnesses I interviewed suggest. This government must learn to empower and delegate – and trust those on the front line.

In care for the elderly it’s a matter of life and death.