The Scottish government has been heavily criticized over the decision to move older people from hospitals to care homes in the early stages of the pandemic, some of whom had tested positive for covid-19. 

Many blame that decision for the outbreaks of covid in care homes that would eventually take thousands of lives.

World-renowned dementia expert Professor June Andrews tells healthandcare.scot that the problem lies less with the decision to discharge patients, though, and more with the fact that they were in hospital in the first place. 

As Scotland prepared for the first wave of covid-19 in March last year, one issue that had dogged the health service for years seemed to be fixed almost overnight.

While government officials moved to respond to an impending public health emergency that might fill hospitals to capacity, older people medically fit to go home but who had been left waiting in hospital – for days, weeks or even months – often because of a lack of social care support for them outside, were moved out into the community at pace.

Delayed discharge statistics had been getting steadily worse in Scotland for some time. Over a matter of days, many of those people were sent to care homes.

A Public Health Scotland report in November found eight in ten of the 3,599 people discharged from care homes between the 1^st March and 21^st of April were tested for covid-19, and of those tested of those tested, 78 received a positive result while in hospital before being discharged.

Professor Andrews says the problem for care homes was not dealing with infected patients per se but dealing with them on an unprecedented scale.

“Care homes have been dealing with infection since time immemorial, with winter flu, norovirus, and other conditions,” she explains.

“The problem for care homes this time was that they were overwhelmed with too many discharges from hospital too quickly at a point when these people were not or could not be tested, and the resulting chaos – including problems of not being able to test staff and the fact the buildings were not designed for this kind of care – meant that there was a catastrophe.

“In a public health emergency mistakes are made; as one of the WHO officials, Dr Michael Ryan said, with the virus, “If you don’t move fast enough you are dead and if you wait until you are absolutely right before you make a move, you are dead.”

“Rapid decisions had to be made because the government was expecting some of the terrible scenes unfolding elsewhere in Europe to come to the UK with people dying on the floor of the hospital.

“And with hindsight, maybe we could have moved older people out more slowly, maybe it could have been a phased approach. But we didn’t do that, we bundled them all out.”

Just over 3,500 people were discharged from hospitals to care homes in Scotland between the 1^st March and the 21^st of April 2020.

Professor Andrews adds: “The research on transition from hospital to a care home is quite clear: it must be managed properly, or it is detrimental to the health of the older person. 

“Even if those people didn’t die of covid they were possibly going to die as a result of the stress of the rapid transfer. There are supposed to be conversations, assessments and even trial visits to see whether or not the care home is the right place for them; the resident and their families are to be involved, the staff of the care home are supposed to get to know them and confirm they can meet their needs. But that didn’t happen.

“And even if there were care homes who felt they didn’t want to accept those people, I understand that many of them couldn’t afford not to accept them, and many of them were put under pressure to accept them against their better judgement. 

“A wrong decision was made which with hindsight you can absolutely understand someone might make out of fear in a public health emergency, but we must remember that the reason that decision had to be made was because a backlog of patients had been allowed to build up. 

“And the reason there was a backlog was because of decades of running the NHS and the care sector in Scotland as if a hospital is a place of safety for an old person, which it is not, and ignoring the population profile. 

“Delayed discharges should not be allowed to build up again…The NHS has at times been given an impossible job because it gives house and home to lots of people who should not be in hospital. 

“That line about saving the NHS which was fundamental to decisions at the time never asked, ‘at what cost?’

“It was at the cost of the people who paid the price - the care home residents who suffered, the care homes who had their reputation trashed, care home staff who died or got sick, staff who had to move into care homes, staff who are still bearing the face-to-face brunt of the anger and pain of the families who haven’t been able to see their relatives for nearly a year.

“Now we are seeing unprecedented denigration of the businesses who have also done their best in this crisis. The suggestion is that a care business is by definition immoral or exploitative.  That’s just not the case. I think care homes have had a really raw deal out of this and to top that off by saying ‘by the way we think you are obscene for making money out of your work’ – that’s just wrong.” 

 

Professor June Andrews explores wider issues around the care home sector in her book Care Homes: Why, When and How to Choose a Care Home.

Sign up to our bulletin for key health & social care updates straight to your inbox.