Caring for our most vulnerable: lessons from COVID-19 on policy changes in the care home sector

If the true measure of any society is how it cares for its most vulnerable, then the catastrophic impact of COVID-19 on care home residents during the first wave of the pandemic was a sad indictment. Older people living in care homes are truly our most vulnerable. They live in care homes because of disability, frailty, and cognitive impairment, and are dependent on staff for round the clock care.

We have learned, over the course of the pandemic, that much can be done to protect care home residents from COVID-19, with measures including routine testing of staff for infection, routine use of personal protective equipment, and careful attention to quarantine of those entering and leaving the home during COVID-19 surges. Even before the successful roll-out of vaccination for residents, there was evidence that these interventions had tempered the worst effects of the second wave of the pandemic. 

However, each intervention implemented for COVID-19 came with a cost. Routine testing placed increased burden on already overwhelmed staff, which distracted from routine care duties at a time when homes were under unprecedented demand. Personal protective equipment interfered with routine communication with residents, many of whom have sensory or cognitive impairment. Quarantine regulations enforced social isolation which has been associated with cognitive and physical decline for residents.     

If policymakers, at times, got the balance between these risks and benefits wrong, then this was a consequence of both the complexity of the situation and the rapidity with which circumstances changed, and changed again, throughout the pandemic. There were, however, ways in which better balance could have been achieved through better understanding of how care in care homes is organised, and the considerable lengths to which staff will go to protect and support their residents.

During the autumn of 2020, as part of the CONDOR-CH study, we conducted research, published in Age and Ageing, that showed for the first time the organisational burden of conducting routine swab testing and sending it off for laboratory Polymerase Chain Reaction (PCR) in care homes.

We had anticipated that this would set the ground for a simplified approach to testing in care homes, including use of point-of-care testing. We set about validating point-of-care PCR and automated antigen testing technologies, showing that these could be feasible and safe if implemented with sufficient awareness of how the care home context differed from the other settings where such tests were deployed.

In practice, policymakers chose to deploy Lateral Flow Tests (LFTs) in care homes. We summarised in our recent Age and Ageing Commentary the issues raised by this. Firstly, there was incomplete adherence amongst care home staff and residents to LFTs regimes, in part a consequence of a substantial burden of work associated with conducting the tests. There was also limited understanding of how false positive and negative results from these tests interfered with the routine of care in care homes. These concerns might have been understood and addressed before roll-out if these technologies had been researched in a similar way to our PCR and automated antigen tests approach.

The Academy of Medical Sciences has neatly outlined that the challenge for the coming winter is not just COVID-19, but rather the combined effects of COVID-19, influenza, and other winter infections such as the Respiratory Syncytial Virus (RSV). LFTs are unlikely to be an effective response to these multiple challenges, because they only test for one pathogen at a time. It is, instead, multiplex testing technologies that will have to be evaluated. The lesson from the introduction of LFTs in the winter of 2020 is that these technologies could be deployed at the point of care in care homes, but only if they are evaluated in this setting to understand how their introduction will affect workflow and day-to-day care.

The bigger issue here relates to how care homes are considered as part of the health and social care sector. The pandemic has seen many policymakers and leaders waking up to how pivotal care homes are to health and social care delivery. This led to a plethora of guidelines, mandates and policies governing long-term care. These have, though, frequently been written with limited understanding of the lived reality of day-to-day life and work in care homes.  

Our work on CONDOR-CH shows how even basic evaluation of new approaches and technologies in care homes can substantially inform their implementation. As governments around the world, including our own governments here in the UK, embark on reform of long-term care, they’d be well advised to ensure that the consequences of implementation are not taken for granted. Time and energy should be invested in understanding the impact of policies and technologies for residents and the staff who care for them. By taking into account such considerations, we’ll be caring for our most vulnerable, and that will reflect well on our society.