tag:theconversation.com,2011:/us/topics/care-homes-7535/articlesCare homes – The Conversation2023-12-28T09:14:42Ztag:theconversation.com,2011:article/2201512023-12-28T09:14:42Z2023-12-28T09:14:42ZThe care home sector got £2.1 billion in government COVID aid – our research shows care workers themselves got little support<figure><img src="https://images.theconversation.com/files/566897/original/file-20231220-27-19tbzb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/persons-hand-in-shallow-focus-CeZypKDceQc">Danie Franco|Unsplash</a></span></figcaption></figure><p>The Coronavirus public inquiry <a href="https://theconversation.com/covid-inquiry-how-it-works-and-when-we-will-know-if-it-is-successful-217718">has made public</a> all manner of decisions taken by the UK government, during the pandemic, that have <a href="https://www.theguardian.com/commentisfree/2023/nov/02/the-guardian-view-on-the-covid-19-inquiry-a-week-that-has-probed-deep">shocked</a> the nation.</p>
<p>In particular, Jenny Harries, current head of the UK Health Security Agency, has been accused of <a href="https://www.theguardian.com/uk-news/2023/dec/02/she-sacrificed-care-home-residents-health-chief-jenny-harries-under-fire-after-uk-covid-inquiry-revelations">failing to protect care home residents</a>, when it emerged that, as England’s deputy chief medical officer, she suggested in March 2020 that COVID-infected patients be discharged from hospital to care homes if the NHS were to be overwhelmed. </p>
<p>Such findings resound in a sector that is in deep trouble. In England, the vacancy rate in the adult social care workforce for 2022-2023 was <a href="https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx">9.9%</a>. That’s <a href="https://www.theguardian.com/society/2023/nov/10/tory-turmoil-hits-efforts-to-fix-staffing-crisis-in-adult-social-care">152,000 vacancies</a> currently unfilled. </p>
<p>Experts <a href="https://theconversation.com/how-did-the-social-care-system-end-up-in-crisis-and-how-can-it-be-fixed-expert-qanda-208920">underline</a> that staffing and financing were problems in the care sector well before COVID arrived in March 2020. The pandemic exacerbated this crisis, despite the extra £2.1 billion in emergency government support, provided during the first year. </p>
<p>My colleagues and I published a <a href="https://ficch.org.uk/resources/reports/">report</a> earlier this year focusing specifically on the financial impact the pandemic has had on care homes for older people in the UK. Very little of that financial support actually went into supporting staff. Of the care workers we spoke to, 42% are in financial distress related to having worked in care homes during the pandemic. </p>
<p>Care homes themselves aren’t faring much better. Six in ten of the UK’s care-home beds are operated by companies that could go bankrupt should they experience even a mild economic shock. </p>
<h2>Care workers in dire straits</h2>
<p>Between October 2021 and April 2022, in collaboration with the <a href="http://chpi.org.uk">Centre for Health and the Public Interest</a> and colleagues at Warwick Business School and University College London, we surveyed 605 care home staff across the UK. We conducted in-depth qualitative interviews with 43 care home staff, including workers and managers. </p>
<p>We found that most of the £2.1 billion in government aid went to covering care homes’ loss of revenue resulting from decreasing occupancy. </p>
<p>Before the pandemic, the occupancy rate was <a href="https://www.nuffieldtrust.org.uk/resource/care-home-bed-availability">87% on average</a> with any drop below 80% putting providers at risk of default. Between March 2020 and April 2021, COVID saw occupancy in the care home sector in the UK decline by 8 percentage points to an average of 79% – the lowest rates recorded <a href="https://www.statista.com/statistics/1231777/care-home-occupancy-in-the-uk/">since 2006</a>.</p>
<p>Much of this is due to the high attrition rate among residents. Over 42,000 care home residents died from COVID-19 between March 2020 and April 2021. One survey respondent put it bluntly: </p>
<blockquote>
<p>I worked for two solid weeks with just a nurse on a dementia [unit]. All 24 residents had COVID and half of them passed away within the two weeks. </p>
</blockquote>
<p>The workforce also suffered higher attrition rates. In the first two years of the pandemic, 1,290 care workers (including those working in domiciliary settings) died as a result of COVID-19. </p>
<p>Severe staff shortages and community health teams suspending their care home visits meant remaining staff had to undertake tasks beyond their remit, for which they were sometimes unqualified. Half of those we interviewed thought their ability to meet residents’ needs was reduced. </p>
<p>Within residential elderly care homes specifically, in the UK, staff vacancy rates in January 2022 reached 11%, a five percentage point increase from April 2021. Combined with staff illness and additional responsibilities, this led to workloads increasing to levels our interviewees described as “intolerable”. </p>
<p>Of the care workers we surveyed, 80% reported working more hours during the pandemic, typically doing 12-hour shifts, as opposed to the <a href="https://www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2022.pdf">seven to eight-hour norm</a>. </p>
<p>Despite these traumatic working conditions, staff reported getting little support. That same care worker told us they had “no cover, zero support from management or anyone else”.</p>
<p>Staff pay remained largely unchanged, except for a one-off bonus of £500, paid out for some workers. There were limited changes to sick pay. And overtime was paid at the regular rate. Taking on extra hours actually put some workers at a financial disadvantage because it reduced their eligibility for in-work benefits. </p>
<h2>A defective funding model</h2>
<p>A 2019 <a href="https://chpi.org.uk/wp-content/uploads/2019/11/CHPI-PluggingTheLeaks-Nov19-FINAL.pdf">report</a> the Centre for Health and the Public Interest thinktank cited the care home sector being “almost entirely provided by independent companies” as a root cause of its structural problems. It highlighted the demise, since 2011, of two major providers, Southern Cross and Four Seasons, which housed 45,000 elderly people between them. </p>
<p>Our findings confirm that the complex funding model on which the care home sector is based is unsustainable. A financial analysis we conducted immediately before the pandemic (March 2020) showed that tight profit margins meant that even a relatively small, 5% decrease in revenue – or equivalent increase in costs – would have put those providers operating over 60% of all UK care home beds into serious financial difficulties. </p>
<p>We examined all publicly available financial data accounts of 4,013 care home companies across the UK, providing 377,856 beds for people aged 65 and over, operating on for-profit and not-for-profit bases. </p>
<p>In total, the government allocated £2.1 billion to the care home sector. The vast majority of this amount went to ensuring its financial viability. </p>
<p>However, we found that while receiving this government support, 122 (27%) of the 460 companies we analysed paid out a total of £120m in dividends, despite increased costs (for infection control, staffing and PPE) and decreased income (due to lower occupancy rates). </p>
<p>This represents a 11% (£11.7m) increase on the previous year. It shows an extraction of profit, especially by some large private providers, in the form of <a href="https://www.theguardian.com/commentisfree/2023/apr/13/britain-care-homes-shareholders-staff-workers-covid-wages">shareholder dividends</a>, from a sector in distress. </p>
<p>For the most part, however, two things kept care homes afloat in the first year of the pandemic. The financial support from the government and care workers working harder and for longer hours. </p>
<p>Government support was terminated in March 2022. The care home financial crisis continues, exacerbated <a href="https://www.nao.org.uk/reports/reforming-adult-social-care-in-england/">by inflation</a> </p>
<p>One finance director of a small non-profit care home told us their annual spend on agency staff has gone from £400,000 a year to over £3.2 million in 2022. A senior manager in another non-profit concurred:</p>
<blockquote>
<p>Our vacancy rates are much higher than they’ve ever been. Our [staff] turnover rate has gone up to about 33%, and we had it down at about 18% before the pandemic. </p>
</blockquote>
<p>Care workers cite exhaustion, disillusionment, illness <a href="https://theconversation.com/why-care-home-staff-in-the-uk-are-at-breaking-point-185234#:%7E:text=On%20an%20individual%20level%2C%20these,turnover%20rates%20and%20staff%20shortages.&text=Managerial%20thinking%20usually%20equates%20reduced%20staffing%20with%20efficiency%20and%20cost%2Dsavings.">and more</a> as reasons for quitting. Care homes have been chronically understaffed for two years, asking more of their remaining staff than they should. </p>
<p>The consequences for the wider population are dire. As one manager told us, the struggle to fill nursing posts – despite what he deemed a “good” starting hourly fee of £21 – means that his small for-profit care home would probably cease offering nursing care. When care homes are at risk of collapse, or unable to fulfil their key tasks elderly people will not receive the services that they urgently need.</p><img src="https://counter.theconversation.com/content/220151/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Marianna Fotaki receives funding from UK Research and Innovation COVID Scheme </span></em></p><p class="fine-print"><em><span>Derya Ozdemir Kaya does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Most of the emergency government aid went to covering care homes’ loss of revenue. Care workers, meanwhile, kept the sector afloat through overtime.Marianna Fotaki, Professor of Business Ethics, Warwick Business School, University of WarwickDerya Ozdemir Kaya, Lecturer in Work and Organisation, University of SussexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2102042023-07-25T16:32:06Z2023-07-25T16:32:06ZPeople with dementia in care homes aren’t getting enough help with their hearing loss – new survey<figure><img src="https://images.theconversation.com/files/539246/original/file-20230725-25-87y32l.jpg?ixlib=rb-1.1.0&rect=8%2C8%2C5742%2C3819&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/doctor-inserting-hearing-aid-senior-patient-630333221">wave break media/Shutterstock</a></span></figcaption></figure><p>Most care home residents have both dementia and hearing loss, which can leave them feeling lonely and depressed. </p>
<p>Hearing loss and dementia both cause difficulties with listening, understanding and communicating. This can lead to breakdowns in relationships because something as simple as a conversation with a loved one can become impossible. </p>
<p>People with dementia often don’t know, or can’t communicate, that they have problems with their hearing. This means that a lot of the time, their carers don’t know either. </p>
<p>Crucially, many people with dementia, and especially those living in care homes, rely on carers to support their hearing needs. This might mean helping with hearing aids or other hearing devices, using communication techniques, writing things down or using flashcards and making sure background noise isn’t too loud. </p>
<p>When hearing care is given properly it can improve residents’ <a href="https://pubmed.ncbi.nlm.nih.gov/34921761/">quality of life</a>, mood and engagement with peers. Unfortunately, in a new study, my colleagues and I found that only <a href="https://www.tandfonline.com/doi/full/10.1080/14992027.2023.2227764">50%</a> of residents with dementia in UK care homes are given help with their hearing loss.</p>
<p>Poorly supported hearing loss leaves residents at risk of emotional and behavioural problems, worsened confusion and difficulties communicating with important people in their life like family, friends, carers and healthcare professionals. In the same study, just 27% of care staff said that they check that residents’ hearing aids are working properly. This is a huge problem as most residents with dementia aren’t able to do this themselves.</p>
<h2>Complicated reasons</h2>
<p>The survey results also revealed that the reasons residents with dementia aren’t receiving help with their hearing are complicated. The biggest problem in care homes appears to be access to resources, such as enough time, enough staff or enough things like hearing aid batteries or flashcards. Staff who completed the survey said that not enough resources in the care homes made it difficult to provide hearing-related care to residents with dementia.</p>
<p>Another part of the problem is that care staff don’t always have the relevant knowledge and skills to help residents with their hearing problems. Just under 25% of staff reported having had any training on hearing loss (despite over <a href="https://rnid.org.uk/wp-content/uploads/2020/05/A1422_Hear_to_Care_Guide_A4.pdf">75%</a> of residents having hearing loss), but almost all said that they wanted this training to be provided. </p>
<p>Hearing loss isn’t always prioritised in care homes. Compared to dehydration, infections or injuries, hearing and communication problems don’t cause immediate risk or physical harm to residents. So helping residents to hear well isn’t often a priority for staff, who have limited time and a heavy workload. That doesn’t mean that hearing and communicating aren’t essential for a person’s wellbeing and happiness. </p>
<figure class="align-center ">
<img alt="People in a care home doing exercise." src="https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/539248/original/file-20230725-20-38r53a.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Hearing loss isn’t always prioritised.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/large-group-happy-enthusiastic-elderly-ladies-367740026">belushi/Shutterstock</a></span>
</figcaption>
</figure>
<p>Results from our survey show that people with dementia living in care homes are not getting the care that they need and deserve to help them to hear, understand and communicate. Care home residents are often very vulnerable, and being able to hear well is essential to maintaining a good quality of life and engaging with <a href="https://www.alzheimers.org.uk/sites/default/files/2022-09/APPG%20on%20Dementia%20Workforce%20Matters%20Report%202022.pdf">mentally stimulating activities</a>.</p><img src="https://counter.theconversation.com/content/210204/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hannah Cross received funding from the Alzheimer's Society to conduct this research. </span></em></p>Half of care home residents with dementia and hearing loss are without any support to communicate.Hannah Cross, Postdoctoral Research Associate, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1905562023-03-23T13:17:06Z2023-03-23T13:17:06ZHow an African church choir made a difference to care home life in Greater Manchester<figure><img src="https://images.theconversation.com/files/516111/original/file-20230317-386-4ty01r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/carer-leading-group-seniors-fitness-class-1178472205">Monkey Business Images/Shutterstock</a></span></figcaption></figure><p>Care homes are rarely a source of good news. The system is <a href="https://theconversation.com/merely-tinkering-expert-analysis-of-the-uk-governments-new-plan-to-reform-social-care-in-england-172085">underfunded</a>, <a href="https://theconversation.com/why-care-home-staff-in-the-uk-are-at-breaking-point-185234">understaffed</a> and <a href="https://theconversation.com/social-care-reform-why-boris-johnsons-plan-wont-fix-the-crisis-expert-view-167472">overextended</a>, and homes are routinely found to be inadequate. Of the 2,934 homes the Care Quality Commission <a href="https://www.itv.com/news/2023-01-24/almost-half-of-all-care-homes-inspected-in-england-found-to-be-failing">inspected</a> in the year to December 2022, 1,224 were deemed inadequate or requiring improvement. </p>
<p>Low expectations and negative stereotypes, particularly in the media, <a href="https://www.sciencedirect.com/science/article/pii/S0890406513000091">exacerbate the problem</a>. But when positive relationships are placed at the centre of adult social care, care homes have the potential to be joyful, lively places. </p>
<p>Our research has looked at what happens when care homes facilitate community connections between their older residents and refugees. We have found that <a href="https://journals.healio.com/doi/abs/10.3928/00989134-20220808-04">singing</a>, in particular, is a good tool for breaking down social barriers, reducing isolation and improving wellbeing. <a href="https://theconversation.com/choir-singing-improves-health-happiness-and-is-the-perfect-icebreaker-47619">Group singing</a> can benefit everyone.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NzhAzicaErI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>How singing improves wellbeing</h2>
<p>From 2016 to 2019, we worked with four care homes in Bolton, Greater Manchester, and a local choir which visited the homes once a month. The residents were older adults, predominantly white British. Some had diagnoses of dementia or mental health problems.</p>
<p>The choir was comprised of six to ten young people and adults from the Ephrata Church Community, a local black African church. They brought keyboards and guitars and set up shop in communal areas. The residents were free to come and go as they pleased.</p>
<p>The choir leader would introduce the songs and distribute lyrics, encouraging both residents and staff to join in. Afterwards they were asked about their experience of the session and whether they had any song requests for subsequent visits.</p>
<p>From the start, residents found the experience to be beneficial. One explained how little there was, usually, for them to do in the care home: “The staff are in rush, and we can’t have a proper conversation.” Research has long shown that this is <a href="https://sigmapubs.onlinelibrary.wiley.com/doi/full/10.1111/jnu.12488">not uncommon</a>. </p>
<p>Joining in the singing project, by contrast, as one member of staff put it, “greatly improved [the residents’] moods and got them up dancing”. Another said how much it “brightens up the lives of people waiting for treatment”. </p>
<p>They especially like the fact that the choristers also learned a thing or two from Googling song requests they weren’t familiar with. One resident said that the song What a Friend We Have in Jesus is their “best song, the song they will sing during my funeral”.</p>
<figure class="align-center ">
<img alt="A group of people in smart clothes stand outside a building." src="https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516360/original/file-20230320-24-rdzouh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Ephrata choir at one of the study care homes.</span>
<span class="attribution"><span class="source">Kayonda Ngamaba</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<h2>How singing fosters connectedness</h2>
<p><a href="https://www.britishacademyofsoundtherapy.com/singing-for-health/">Singing has been shown</a> to boost confidence, broaden communication skills and foster connections with others. The <a href="https://theconversation.com/looking-for-a-nursing-home-place-for-your-parent-with-dementia-heres-what-to-consider-63121">physiological benefits</a> it brings are clear too: as a workout, it can strengthen the immune system, improve posture and aid sleep. It is also a natural <a href="https://theconversation.com/reducing-depression-in-nursing-homes-requires-more-than-just-antidepressants-38970">antidepressant</a>, lowering <a href="https://journals.sagepub.com/doi/full/10.1177/13591053211012778">stress levels</a> and improving mental alertness. </p>
<p>Research shows that <a href="https://journals.sagepub.com/doi/full/10.1177/03057356211042668">group singing</a>, specifically, increases levels of oxytocin, which fosters a greater sense of <a href="https://www.sciencedirect.com/science/article/pii/S0306453013002369">connectedness</a> and contentment. </p>
<p>Context, however, mediates the impact of oxytocin. Hence, before the singing, each chorister introduced themselves, the school they go to (for children), the work they do, their hobbies and preferred food. This started a conversation with the residents, about having gone to the same school or liking the same food. </p>
<p>Group bonding can happen <a href="https://www.sciencedirect.com/science/article/pii/S1090513815001051">quickly across large groups</a> when people have a shared motivation or focus; when their activities are aligned in what psychologists call behavioural synchronicity; and when they experience a collective sense of achievement. Rather than inviting residents to watch a performance, the fact that these sessions involved the choristers using songs chosen by the residents and actively encouraging them to clap and sing along encouraged connection. </p>
<p>The benefits of a greater sense of connection are clear. Loneliness is an enduring problem for older adults, especially in care homes. Despite living in shared accommodation, <a href="https://academic.oup.com/ageing/article/49/5/748/5827763?">over 60%</a> of older adults in care homes are moderately or severely lonely. Some studies show <a href="https://www.magonlinelibrary.com/doi/abs/10.12968/ijtr.2006.13.8.370">only 10% of care home residents’ time</a> involves social interaction. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/Bq3xj0XKcvI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>On a societal level, fostering connections can contribute to reducing social stigma, prejudice and isolation – issues faced by older adults and refugees alike. Spending time together (what psychologists term <a href="https://guilfordjournals.com/doi/abs/10.1521/soco.2008.26.3.259">the “mere exposure effect”</a>) can be enough to generate familiarity. </p>
<p>In addition, introductions at the start of singing emphasised the idea that <a href="https://compass.onlinelibrary.wiley.com/doi/full/10.1111/spc3.12000">everyone is unique</a> – it reduced the perceived homogeneity of “older people” or “refugees”. Research suggests that <a href="https://journals.sagepub.com/doi/full/10.1177/0956797613481607">environmental cues</a> of social connectedness (sharing an activity, say, like singing together) also reduce bias. On a more basic level, the signing group challenges stereotypes of refugees <a href="https://www.jstor.org/stable/42889189">as hostile and taking resources</a>, to being ordinary and active members of their communities who make a positive contribution.</p>
<p>Further, better relationships between caregivers and care home residents <a href="https://journals.sagepub.com/doi/10.1177/1471301209350285">can reduce staff burnout</a> because they make the work more meaningful and rewarding. It acts as a buffer against stress, and some of the <a href="https://psycnet.apa.org/record/2018-18711-001">more difficult aspects</a> of caregiving, such as working with aggression in people with dementia. This is known as “enrichment”, where caregiving <a href="https://pubmed.ncbi.nlm.nih.gov/36687423/">gives meaning and pleasure</a> to both parties, by giving something back to a previous generation, enjoying each other’s company, or learning something new.</p>
<figure class="align-center ">
<img alt="A group of people stand in a hall holding up pieces of paper." src="https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/516364/original/file-20230320-16-ilkzbz.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Ephrata choir volunteers.</span>
<span class="attribution"><span class="source">Kayonda Ngamaba</span>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span>
</figcaption>
</figure>
<p>Social care experts speak about <a href="https://www.emerald.com/insight/content/doi/10.1108/JOSM-11-2019-0346/full/html">“older-adult-centred care”</a> wherein people are as autonomous as possible. This involves treating them with dignity, providing personalised support for their unique needs, and creating a social environment in which people feel meaningfully included. </p>
<p>Our research suggests there is an important fifth component – reciprocity – which is all about finding ways for older people <a href="https://www.emerald.com/insight/content/doi/10.1108/14717794200600015/full/html">to actively contribute</a> to wider community life. When, conversely, they receive care passively, it can create <a href="https://pubmed.ncbi.nlm.nih.gov/30514117/">an objectified, distanced relationship</a> that reduces the sense of reward for everyone involved.</p>
<p>Our group singing project delivered on all fronts. Participants were treated with respect and involved in decision making. They forged connections with the choristers and each other, shared personal experiences and knowledge. </p>
<p>Greater community cohesion was achieved too, with connections forged between two groups so often isolated. As one younger member of the African choir said: </p>
<blockquote>
<p>I really enjoy singing today, it helps me to be connected.</p>
</blockquote><img src="https://counter.theconversation.com/content/190556/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kayonda Hubert Ngamaba is volunteer at Ephrata Church Community.</span></em></p><p class="fine-print"><em><span>Cheyann Heap does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Singing, as a communal exercise, can break down social barriers, reduce isolation and improve wellbeing.Kayonda Hubert Ngamaba, Research Fellow, Social Policy and Social Work Department, University of YorkCheyann Heap, Research Associate, Community-Enhanced Social Prescribing, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1868062022-08-24T16:32:39Z2022-08-24T16:32:39ZThe pandemic changed what it means to have a ‘good death’<figure><img src="https://images.theconversation.com/files/480116/original/file-20220819-2895-2z5zso.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C5145%2C3437&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The fear of not having a “good death,” by dying at home among family members, has become a very real concern — especially during the pandemic.</span> <span class="attribution"><span class="source">(Anton Darius/Unsplash)</span></span></figcaption></figure><p>When considering what a “good death” is, most people in North America would likely say something along the lines of living to at least 75, and painlessly passing away at home in their sleep would constitute <a href="https://www.theatlantic.com/magazine/archive/2014/10/why-i-hope-to-die-at-75/379329/">a good life and, most importantly, a good death</a>. One of the key features of the “good death” narrative is being at home.</p>
<p>So, what do we mean by home and how important is the idea or feeling of “being at home” to a good death? </p>
<p>Home is <a href="https://thecorrespondent.com/427/why-the-meaning-of-home-has-changed-now-that-we-cant-leave-the-house">more than just a structure</a>. It is textures, smells, sounds and atmosphere. It is a sticky table that brings you back to your first day of school when you held your brother’s hand as you both walked to the bus or a smell that reminds you of the first time you baked cookies with your grandmother and danced around the kitchen singing along to Cher. </p>
<p>Home is nothing, but everything, especially at the end of life.</p>
<p>Death used to be treated as a public event, but as our society has become more <a href="https://www.jstor.org/stable/3631614">individualistic</a>, it has shifted to being a matter best dealt with in private <a href="https://doi.org/10.2307/j.ctv1fj84sj">by ritual specialists</a> — like an embalmer or funeral director — and close family members. </p>
<p>As the home is thought of as being the most intimate private space we inhabit, it should not be surprising that most people wish to seek <a href="http://www.hpcintegration.ca/media/51032/The%20Way%20Forward%20-%20What%20Canadians%20Say%20-%20Survey%20Report%20Final%20Dec%202013.pdf">“home” in the dying process</a>. To die outside of home is seen to be a failure — a bad death.</p>
<p>The pandemic changed the lives of many people. Isolated from friends and family, away from home, many people didn’t have access to a “good death” — especially those in care homes. So its important to reflect back on this idea of a “good death” and how we understand what home and family mean.</p>
<h2>No longer an ‘uncomplicated’ death</h2>
<p>Since the 1920s and ‘30s the government has increased its control over <a href="http://www.cindea.ca/home-funerals.html#history">funerals and end-of-life treatments</a>. This became an even greater concern in the 1950s and '60s, when advancements in medical care meant that people who would have previously had an <a href="https://www.jstor.org/stable/648663">“uncomplicated”</a> death now found themselves entangled in, and dependant on medicine.</p>
<p>With an aging population and medical advancements, the reality is that as people age, they are likely to find themselves being put in the role of “<a href="https://doi.org/10.1136%2Fbmj.39244.650926.47">patient</a>,” where their death will be <a href="https://www.health.harvard.edu/blog/where-people-die-2018103115278">medically mediated</a>. </p>
<p>This means that even if they are able to be at home, their health is being medically determined, with the end result being that the amount of control they have over their own lives and final care has become complicated. </p>
<p>The ideal narrative of living to 75 and passing away at home quietly and painlessly while asleep is becoming increasingly difficult to realize. </p>
<figure class="align-center ">
<img alt="A person stands behind square windows, wearing scrubs, wiping down a desk" src="https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/479483/original/file-20220816-10961-s6r1xw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A worker is seen cleaning surfaces inside a long term care home in Vancouver.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<h2>No longer at home</h2>
<p>The fear of not having a <a href="https://www.researchgate.net/publication/287324532_Beyond_the_good_death_The_anthropology_of_modern_dying">“good death,”</a> by dying at home among family members, has become a very real concern — especially during the pandemic. </p>
<p>Before COVID-19, people who lived in places like care homes would still be invited to gatherings or enjoy the occasional visit from a loved one. Their <a href="https://www.ncbi.nlm.nih.gov/books/NBK464649/">social death</a> was isolating, but not devastating. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/non-profit-long-term-care-homes-have-lost-too-many-residents-to-covid-19-161060">Non-profit long-term care homes have lost too many residents to COVID-19</a>
</strong>
</em>
</p>
<hr>
<p>During peak restrictions, senior living and care facilities were locked down. This resulted in family members feeling helpless and those living in care facilities feeling hopeless. </p>
<p>The shutdowns, intended to keep them safe, caused many to long for a home that wasn’t restricted — some even opted to <a href="https://www.ctvnews.ca/health/facing-another-retirement-home-lockdown-90-year-old-chooses-medically-assisted-death-1.5197140">choose medically assisted death in the face of additional lockdowns</a>.</p>
<h2>An evolving 'good death’</h2>
<p>In the Netherlands, home is thought of as not just being a physical space, but is seen as <a href="https://cap-press.com/books/isbn/9781594605185/The-Maintenance-of-Life">a state of being in the family</a>. </p>
<p>Isolated from their families during the pandemic, many individuals found themselves no longer being <em>in</em> the family. The social death they were experiencing was felt to be far more painful than any fear or concern they had about their own biological death. </p>
<p>As we reflect on what life means to us in this post-pandemic shuffle, we need to also contemplate what a “good death” is. For some, that may mean opting for quality of life and control over how, when, with whom and where it ends through end-of-life programs like <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html">MAID (Medical Assistance in Dying)</a>. </p>
<p>The pandemic will forever change how people understand what home and family means, what their role within the family and home is, and how to be in the family and <a href="https://palliative.stanford.edu/home-hospice-home-care-of-the-dying-patient/where-do-americans-die/">in the home, in whatever form that may be, for their passing</a>.</p><img src="https://counter.theconversation.com/content/186806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Charisma Anne Thomson does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As we reflect on what life means to us in this post-pandemic shuffle, we need to also contemplate what a “good death” is.Charisma Anne Thomson, Lecturer, Anthropology, University of ReginaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1852342022-06-20T14:11:41Z2022-06-20T14:11:41ZWhy care home staff in the UK are at breaking point<p>Since the post-COVID reopening of the economy, staffing shortages in the care sector in England have been of increasing concern. In October 2021, British charity Skills for Care <a href="https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx">warned</a> that, at 8.2%, adult social care vacancy rates in England were exceeding pre-pandemic levels (which in 2019, stood at 8%). That figure has since <a href="https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/COVID-19/Vacancy-information-monthly-tracking.aspx">exceeded 10%</a>, according to Skills for Care’s monthly tracking. </p>
<p>The UK government has sought to remedy this crisis, in part, with the new health and social care levy, which came to force in April 2022. This levy is currently being implemented as an increase in <a href="https://theconversation.com/national-insurance-a-uk-tax-which-is-complex-and-vulnerable-to-political-intervention-167552">National Insurance</a> contributions.</p>
<p>Experts have pointed out that this is having a disproportionate impact on household budgets for those on lower incomes and those below the age of 50. They have also <a href="https://theconversation.com/social-care-reform-why-boris-johnsons-plan-wont-fix-the-crisis-expert-view-167472">warned</a> that it <a href="https://theconversation.com/merely-tinkering-expert-analysis-of-the-uk-governments-new-plan-to-reform-social-care-in-england-172085">won’t fix the problem</a>. </p>
<p>This is because a relatively small portion – £5.4 billion of the £39 billion to be raised in the next three years – is set to go to social care, with the remainder to be spent on the NHS. And half of that £5.4 billion will be used to compensate for the cap on care costs of self-funders. Crucially, only £500 million has been allocated to workforce reform, and this amount is to be spent, not on <a href="https://www.ft.com/content/655cef78-2422-4c95-b709-0406519572ca">the pay uplift so desperately needed</a> for recruitment and retention, but on training and qualifications. </p>
<p>Our <a href="https://ficch.org.uk/about/">ongoing research</a> (the results of which are not yet published) looks at the financial impact COVID has had on care homes for older people and their staff. We interviewed managers, care-giving staff and support staff from for-profit and non-for-profit providers of all sizes. We have found that many people don’t think carers need more training – they are, as some reminded us, among the best trained workforce in the economy. What they do need is improved working conditions and better pay. </p>
<figure class="align-center ">
<img alt="A carer gives an elderly lady her dinner in a kitchen setting." src="https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469490/original/file-20220617-14-r97cqv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Care homes are struggling to find qualified nurses and to retain care staff.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/care-worker-giving-old-lady-her-482413708">DGLimages | Shutterstock</a></span>
</figcaption>
</figure>
<p>Conversely, <a href="https://www.skillsforcare.org.uk/adult-social-care-workforce-data/Workforce-intelligence/publications/Topics/Nurses-in-social-care.aspx">the shortage of qualified nurses</a> is one of the biggest pressures on both nursing homes and on the <a href="https://www.kingsfund.org.uk/sites/default/files/2022-03/Health%20and%20Social%20Care%20Committee%20workforce%20inquiry%20recruitment%2C%20training%20and%20retention%20in%20health%20and%20social%20care_for%20uploading_0.pdf">NHS</a>. Therefore, rather than offering more training to existing carers, we need to improve pay and conditions of care home staff and to train new nurses to work in the sector. </p>
<h2>Pandemic effects on workforce</h2>
<p>From senior managers to carers, people employed in the care sector repeatedly emphasised that better pay and working conditions were crucial to filling the care workforce shortages. Measures already taken towards further professionalisation – such as the carers’ registry established in Scotland in 2001 – <a href="https://digitalpublications.parliament.scot/ResearchBriefings/Report/2020/12/3/92a1d806-219e-11ea-b692-000d3a23af40">have been shown</a> to have done nothing to improve pay and conditions for carers and, by extension, staffing. </p>
<p>Although social care benefited in 2020 from COVID closures in sectors recruiting from the same labour pool, it has been <a href="https://www.theguardian.com/society/2022/jan/13/staffing-at-uk-care-homes-30-less-than-needed-survey-finds">struggling</a> in the past year <a href="https://www.thetimes.co.uk/article/hospitals-face-bottleneck-as-care-homes-run-short-of-staff-n9w23sh9w">to compete</a> for talent. Retail and tourism in particular offer <a href="https://www.theguardian.com/society/2021/sep/04/care-workers-in-england-leaving-for-amazon-and-other-better-paid-jobs">higher wages</a> and better working conditions. And people working in these sectors tend to enjoy comparatively higher social esteem for roles that are less mentally and physically demanding. </p>
<p>The <a href="https://www.theguardian.com/society/2022/jan/13/staffing-at-uk-care-homes-30-less-than-needed-survey-finds">media</a> has <a href="https://www.thetimes.co.uk/article/stop-inspecting-and-muck-in-struggling-care-homes-appeal-to-watchdog-02gr6q5jv">periodically</a> pointed out <a href="https://www.bbc.co.uk/news/uk-61413697">the immense strain</a> that the pandemic placed on the care workforce. But the sheer extent of the pressure our carers have endured is staggering.</p>
<p>Care home staff continue to experience crushing workloads. Many have worked 14-16 hours a day, for weeks on end without a break, and many months without a holiday. </p>
<p>They have also endured devastating COVID outbreaks at various stages of the pandemic. While these have claimed mostly frail residents’ lives, <a href="https://www.theguardian.com/society/2022/may/05/care-homes-in-england-demand-revival-of-covid-fund-to-pay-isolating-staff">workers too</a> have been affected. They have lived and worked with the constant fear of catching and bringing COVID into care homes as a result. </p>
<p>The consequent prevention measures, whether mandated by government or employers or self-imposed, have led to social isolation. Early on in the pandemic, it was not uncommon for care home staff, including managers, to move into their workplaces or avoid social contact, in order to minimise the risk to their residents and families. </p>
<p>The government’s rules changed over time but as our ongoing study and media reports show, care staff have felt keenly that they are living by different rules to the rest of the society. When the end of lockdown, on July 19, 2021, was dubbed “Freedom Day”, carers and <a href="https://www.bbc.com/news/uk-57643063">the vulnerable people they care for</a> rightly resented that description. </p>
<p>On an individual level, these workloads, working conditions and emotional pressures have led to to <a href="https://publications.parliament.uk/pa/cm5802/cmselect/cmhealth/22/2202.htm">high burnout rates</a> and mental health concerns. Sector-wide, this has resulted in ever higher staff turnover rates and staff shortages.</p>
<figure class="align-center ">
<img alt="A medical worker in protective gear and and scrubs looks at the camera." src="https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469484/original/file-20220617-15-fgsz29.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The pandemic has put care home staff under immense pressure.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-handsome-serious-doctor-wearing-face-645827014">RenysView | Shutterstock</a></span>
</figcaption>
</figure>
<p>Managerial thinking usually equates reduced staffing with efficiency and cost-savings. But we are finding that staff shortages in care homes are actually costing the sector dearly. <a href="https://www.carehome.co.uk/news/article.cfm/id/1663313/staff-shortages-care-homes-close">Providers</a> are <a href="https://www.itv.com/news/2021-10-13/care-homes-are-in-crisis-pm-told-urgent-action-to-prevent-more-closures">struggling</a> to keep services running. Staffing agencies’ fees have reportedly <a href="https://www.theguardian.com/society/2021/nov/14/staffing-agencies-triple-rates-as-care-homes-and-nhs-fight-over-nurses">skyrocketed</a>, and due to sponsorship costs and visa fees, overseas recruitment is <a href="https://www.theguardian.com/society/2022/mar/27/overseas-nurses-in-the-uk-forced-to-pay-out-thousands-if-they-want-to-quit-jobs">similarly costly</a>. And there are the usual recruitment costs <a href="https://www.healthrecruitnetwork.co.uk/blog/2021/07/the-cost-of-high-staff-turnover-in-care-homes">which accumulate</a> with higher staff turnover.</p>
<p>Care home providers’ spending are increasing elsewhere too, as overheads become <a href="https://blogs.kcl.ac.uk/socialcareworkforce/2022/03/30/living-costs-and-care-home-providers/">more expensive with inflation</a>. Those who have significant amounts of state-funded residents are unable to pass on the additional costs and are thus feeling the squeeze. Large private chains <a href="https://www.ft.com/content/9a7ae1e7-036d-48a4-8aed-80e7803d84bc">have already announced</a> they will increase fees up to 10% this year citing staff shortages as a prominent reason in addition to soaring food and energy prices.</p>
<p>The social care reform which the government has begun to implement comes nowhere near resolving this crisis. It is clear that spending more on staff will benefit everyone – service users, service providers, workers, and, ultimately, the taxpayer.</p><img src="https://counter.theconversation.com/content/185234/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Derya Ozdemir Kaya currently works on a project investigating the financial impact of COVID-19 on care homes and their staff funded by the Economic and Social Research Council (ESRC).</span></em></p><p class="fine-print"><em><span>Marianna Fotaki leads on a project that is funded by the UKRI Covid scheme ‘’Understanding the financial impact of Covid-19 on the UK care home sector - implications for business and the workforce’</span></em></p>Care workers in England have faced impossible pressures during lockdown. The government needs to ensure better pay and working conditions.Derya Ozdemir Kaya, Research fellow in Organisation and Work, Warwick Business School, University of WarwickMarianna Fotaki, Professor of Business Ethics, Warwick Business School, University of WarwickLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1739352022-01-05T12:43:57Z2022-01-05T12:43:57ZIntegrating health and social care: seven steps for success<figure><img src="https://images.theconversation.com/files/438950/original/file-20211223-49721-1mkxenp.jpg?ixlib=rb-1.1.0&rect=16%2C10%2C3573%2C2371&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/parkinson-disease-patient-alzheimer-elderly-senior-1702101469">Chinnapong/Shutterstock</a></span></figcaption></figure><p>The widespread deaths of the <a href="https://www.health.org.uk/news-and-comment/charts-and-infographics/deaths-from-any-cause-in-care-homes-have-increased">elderly in care homes</a> that occurred as a result of poor decisions by government at the start of the COVID-19 pandemic, revealed the lack of knowledge about how the care sector works. </p>
<p>COVID also highlighted the challenges of managing public services and responding to ongoing uncertainty. This includes ensuring that different, but related, services such as health and social care, <a href="https://www.kingsfund.org.uk/blog/2020/04/health-social-care-covid-19-coronavirus">join up successfully</a>. </p>
<p>The idea to integrate public services has been a <a href="https://www.tandfonline.com/doi/full/10.1080/21582041.2020.1824078">trend</a> across western Europe relatively long before the pandemic. In Scotland, for example, a <a href="https://www.gov.scot/policies/social-care/health-and-social-care-integration/">flagship social policy</a> centres on the need to integrate social care, historically managed by local government, with healthcare – historically managed by the NHS. The desire to integrate these two key services has been ongoing since 2016, commanding widespread political support.</p>
<p>Europe-wide <a href="https://www.tandfonline.com/doi/full/10.1080/21582041.2020.1824078">research</a>, including some from <a href="https://siscc.dundee.ac.uk/wp-content/uploads/2020/04/siscc-copro-redux.pdf">Scotland</a>, has highlighted the leadership and management challenges around the issue. From these studies, seven key lessons have emerged will help to ensure the successful integration of two of our most important public services.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2xVeRwX5v9U?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<h2>1. Proper political support is required</h2>
<p>Without sufficient central government support, innovative and creative attempts to integrate often fail – as happened with the UK’s <a href="https://www.suttontrust.com/wp-content/uploads/2018/04/StopStart-FINAL.pdf">Sure Start children’s centres</a>. A programme designed to improve the prospects of children in deprived areas, its ring-fenced budget was removed and the initiative <a href="https://www.theguardian.com/politics/2019/jun/16/sure-start-numbers-plummet-as-cuts-hit-childrens-services">suffered from cuts</a>. This led to a sharp fall in the numbers of children attending and benefiting from Sure Start – many of whom lived in the poorest areas of the country.</p>
<p>This is what happens when government – central or local – takes a hands-off approach to the integration of health and social care and bears no responsibility for its progress (or lack of it) at local level. Government must be held to account for the way it rolls out and maintains national public policies. </p>
<h2>2. Community involvement is key</h2>
<p>Support from local groups and community involvement is a predictor for success in integrating these services. Although health and social care partnership areas can help local groups and organisations work together (there are 31 in Scotland, for example), concerns have emerged over quality and accountability of services once they are outsourced to other sectors, such as voluntary or private. But outsourcing is <a href="https://bristoluniversitypress.co.uk/outsourcing-in-the-uk">commonplace</a> within health and social care, and is how public services are often managed. There must be better government oversight of the outsourcing process, and acknowledgement of how communities themselves can shape health and social care.</p>
<h2>3. Professionals must be prepared to integrate</h2>
<p>Sometimes those working in health and social care are reluctant to integrate. Professional boundaries relating to differences in status can create friction. Differing health backgrounds – some based on medical training and some based on social care training – are often barriers to professionals coming together.</p>
<p>A mismatch in cultures, behaviours and understanding of services can create a divide between health and social care. This in turn, makes it harder to establish a clear purpose and agree on longer-term objectives for integration. </p>
<p>Multi-agency team managers need to reach out to the local community to develop broader partnerships. It is also important to provide staff development opportunities, working across this divide to improve understanding of other disciplines.</p>
<h2>4. Shared values and goals are fundamental</h2>
<p>For services to work together successfully, there needs to be a <a href="http://archive.isotis.org/wp-content/uploads/2018/06/D6.2.-Review-on-inter-agency-working-and-good-practice.pdf">common purpose</a>. Strong, effective partnerships depend on the commitment of those taking part. Defining a clear purpose at all levels is key, as well as clarifying roles and responsibilities to engender trust, understanding and respect. </p>
<figure class="align-center ">
<img alt="Young healthworker attending an elderly person outside in a garden during COVID-19." src="https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/438952/original/file-20211223-13-bllqt6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Policymakers must listen to frontline health and care workers and learn from their experiences.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/image-aged-african-man-being-checking-1767755399">Kwame Amo/Shutterstock</a></span>
</figcaption>
</figure>
<h2>5. Clarity: accountability, communication and data sharing</h2>
<p>Strong relationships and effective communication are key to successful integration. In practice this means both at worker-to-worker level and worker-to-client level. Collaborating and sharing relevant information between agencies requires shared management systems with common IT systems and formal agreements on things such as data sharing and constructive performance management systems. </p>
<h2>6. Short-term funding doesn’t work</h2>
<p>A long-term funding model is crucial for effective inter-agency working. For integration to work, there needs to be sustained funding through budget sharing, realistic staffing and timescales – with time built in for planning, and proper support. Insecure funding is a barrier in the long-term. </p>
<p>Currently, the integration of health and social care in Scotland, for example, doesn’t have a sustainable funding model due to the state of public finances (which are linked to austerity measures), coupled with the high costs of an ageing population. </p>
<h2>7. People need to know if they’re getting it right</h2>
<p>Developing the skills of managers in health and social care is important because not everyone possess the tools to evaluate what actually works. Often there is heavy focus on performance monitoring over investigating the actual changes that have emerged from integration initiatives. </p>
<p>National government agencies which regulate and inspect health and social care need to provide practical ongoing research support to help professionals continue their learning and access the expertise and resources they need to know what works. </p>
<p>When it comes to integrating public services, the “how” is just as important as the “why”, and strong leadership is important. Policymakers need to listen to those on the frontline and demonstrate that their knowledge and experience are valued. For the general public, integrating these two services will mean receiving joined-up care and support when they need it most.</p><img src="https://counter.theconversation.com/content/173935/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Connolly has received funding from the Scottish Improvement Science Collaborating Centre to undertake research into the leadership of health and social care in Scotland. </span></em></p>The deaths of huge numbers of the elderly in our care homes due to COVID-19 made clear the need to integrate our health and social care services. Here’s what needs to be done.John Connolly, Professor of Public Policy, University of the West of ScotlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1720852021-12-03T15:42:43Z2021-12-03T15:42:43Z‘Merely tinkering’: expert analysis of the UK government’s new plan to reform social care in England<figure><img src="https://images.theconversation.com/files/435596/original/file-20211203-13-e6snjz.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Even before the pandemic, there were over 124,000 care-worker vacancies in the UK.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/portrait-asian-physiotherapist-carer-helping-playing-1803598954">Art_Photo | Shutterstock</a></span></figcaption></figure><p>The UK government has published details of how it plans to reform adult social care in England. On December 1, in the House of Commons, Care Minister Gillian Keegan <a href="https://hansard.parliament.uk/Commons/2021-12-01/debates/7FF40A74-82C1-4296-BDFE-505C1EC14E04/AdultSocialCare">introduced</a> an “ambitious 10-year vision”, which was first <a href="https://researchbriefings.files.parliament.uk/documents/CBP-8001/CBP-8001.pdf">promised</a> four years ago and is entitled People at the Heart of Care.</p>
<p>The white paper lays out how the government intends to spend the funds raised by the new health and social care <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care/build-back-better-our-plan-for-health-and-social-care#our-new-funding-plan">levy</a> announced in September. Much like the £86,000 <a href="https://theconversation.com/social-care-cap-how-the-new-system-will-work-and-why-its-unfair-an-expert-explains-172431">cap</a> on lifetime care costs, on which the House of Commons voted in November, however, it has already proven <a href="https://www.theguardian.com/society/2021/dec/01/jeremy-hunt-and-labour-attack-ministers-social-care-plan">controversial</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/social-care-reform-heres-why-this-tax-rise-isnt-just-unfair-on-young-people-167473">Social care reform: here's why this tax rise isn't just unfair on young people</a>
</strong>
</em>
</p>
<hr>
<p>In 2019, Boris Johnson <a href="https://www.gov.uk/government/speeches/boris-johnsons-first-speech-as-prime-minister-24-july-2019">promised</a>, in his first speech as prime minister, to “fix the crisis in social care once and for all”. And Keegan was emphatic that the government is determined to get it right. “After all,” she said, “we cannot be serious about levelling up unless we are also serious about social care.” </p>
<p>Keegan’s Labour counterpart, Liz Kendall, and former Tory health secretary Jeremy Hunt, among others, were unimpressed. The plan, they claimed, fails to deal with immediate pressures on the social care system and in particular on its workforce. In the long term, meanwhile, it proposes little that is new. Crucially, the white paper is vague on key details and the government’s budget for it falls far short of what’s needed to make it happen. </p>
<figure class="align-center ">
<img alt="An interior shot of a woman wearing a blue headscarf and a checkered dress in a wheelchair." src="https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435592/original/file-20211203-21-1ootx31.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The plan includes modest funding for home improvements for people who need care and support at home.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/beautiful-young-woman-hijab-disabled-person-1275257290">Petrushin Evgeny | Shutterstock</a></span>
</figcaption>
</figure>
<h2>Long-term plans</h2>
<p>The broad aims of the plan – to give people “choice, control and support to live independent lives”, through care and support that is fair, accessible and tailored to their needs – are not new. These basic principles have been widely discussed since at least <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/272101/6499.pdf">2005</a>. </p>
<p>The specific proposals outlined cover similarly familiar territory. It offers modest new funding to explore ways of tackling major and longstanding care workforce issues, including the need for upskilling and better working conditions, but nowhere near enough. In many areas, services similar to those proposed existed in various forms before the austerity-induced cuts of the 2010s and the havoc wrought by the pandemic.</p>
<p>Keegan says the new plan addresses past governments’ failures to invest in preventative services or to focus on wellbeing. The new funds are being allocated to several things that will make a difference: greater uptake of technology and digitisation (£150 million); a practical service to make minor repairs and changes in the homes of people who receive care; enhanced housing options for supported living (£300 million); support for unpaid carers – family members, neighbours and friends – who provide invaluable informal care, and whose rights to support under the Care Act 2014 have yet to materialise in practice (up to £25 million). </p>
<p>Elsewhere, a campaign and new <a href="https://engage.dhsc.gov.uk/social-care-reform/?link_index=6">website</a> are planned to help people find out more easily how to get the care they need. Finally, to tackle longstanding problems with vacancies and recruitment, £500 million is set aside for care workforce training and development. </p>
<p>While welcome, all of this is significantly less than the amount the House of Commons Health and Social Care Committee <a href="https://committees.parliament.uk/committee/81/health-and-social-care-committee/news/120204/mps-call-for-7bn-annual-increase-in-social-care-funding-as-a-starting-point-for-reform-doing-nothing-no-longer-an-option/">called for</a> in 2020. Hunt, who chairs that committee, said £7 billion would only be enough to “meet demographic and wage pressures, as well as the catastrophic care costs faced by people with dementia or other neurological conditions.”</p>
<p>For Hunt, the government’s new plan thus represents “three steps forward and two steps back”. As an investment, it falls far short of what is needed to fund local authorities’ core responsibilities or to tackle the now urgent care workforce crisis. </p>
<figure class="align-center ">
<img alt="A carer wearing a mask and holding a clipboard looks out of a window." src="https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/435599/original/file-20211203-27-30z5pc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The care workforce requires substantially greater investment in the short and longer term.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-sad-female-caucasian-uk-us-1701457318">Cryptographer/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Thoroughly underfunded</h2>
<p>In 2019, the House of Lords Economic Affairs Committee put the cost of reforming social care at <a href="https://www.parliament.uk/business/lords/media-centre/house-of-lords-media-notices/2020/jul-20/social-care-sector-needs-8-billion-now-not-in-the-distant-future/">£8 billion</a> a year. The total allocated here, over three years, however, is £5.4 billion, £3.6 billion of which is already earmarked to fund the care costs cap and more generous means testing. </p>
<p>Unpaid carers, of whom there are an <a href="https://www.carersuk.org/for-professionals/policy/policy-library/carers-week-2020-research-report">estimated</a> 13.6 million, get mere crumbs from the table: how far will £25m go to improving the support they get? Some disabled and older people may get modest and much needed extra help to live independently at home. Conversely, the unmet need and pressures spilling over from social care into the NHS lack the attention they urgently require. </p>
<p>Crucially, despite everyone from <a href="https://www.kingsfund.org.uk/audio-video/key-facts-figures-adult-social-care">think tanks</a>, care sector <a href="https://www.local.gov.uk/about/campaigns/lives-we-want-lead-lga-green-paper-adult-social-care/towards-sustainable-adult">organisations</a>, charities concerned with <a href="https://www.local.gov.uk/about/campaigns/lives-we-want-lead-lga-green-paper-adult-social-care/towards-sustainable-adult">older</a> and <a href="https://in-control.org.uk/charging-social-care-tax-need-support/">disabled</a> people and <a href="https://www.careandsupportalliance.com/wp-content/uploads/2021/03/CSA_A_Cry_for_Hope_Survey_2021.pdf">carers</a> and <a href="https://publications.parliament.uk/pa/ld201719/ldselect/ldeconaf/392/392.pdf">parliamentary committees</a> long emphasising the need for a radical overhaul of the system, this plan suggests the government does not appreciate the urgency. </p>
<p>Workforce shortages alone amply demonstrate this need. Even before the pandemic there were upwards of 124,000 vacancies. By 2030, projected shortages (due in part to an ageing population) are set to rise to <a href="https://www.theguardian.com/society/2021/nov/22/new-social-care-cap-england-safetey-net-big-step-forward-tackling-lottery-old-age">627,000 care worker vacancies</a> in England alone. This plan does little to address either the immediate problem, for this winter, or the longer-term issues of low pay and poor working conditions.</p>
<p>Since 2010, the UK’s Conservative-led administrations have had a mixed record on social care. While the <a href="https://www.legislation.gov.uk/ukpga/2014/23/contents">Care Act 2014</a>, under David Cameron’s Coalition government, was undoubtedly a high point – putting fairer care funding recommendations, new rights for carers and the core principles of wellbeing and prevention into statute – its reforms were inadequately funded. And subsequent administrations <a href="https://researchbriefings.files.parliament.uk/documents/CBP-8001/CBP-8001.pdf">delayed</a> many of its key <a href="https://www.carersuk.org/for-professionals/policy/policy-library/delayed-implementation-of-care-act-phase-two-implications-for-carers-their-families-and-the-wider-care-system">provisions</a>. </p>
<p>The government’s new vision is one almost everyone else has long been signed up to. But few think the plan provides adequate detail or funding to make it a reality. Care is the crucial underpinning of all our everyday lives. Merely tinkering with the system, as this long-awaited white paper does, leaves me disappointed and angry about what could, and should, have been offered.</p><img src="https://counter.theconversation.com/content/172085/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sue Yeandle receives funding (via her employer, the University of Sheffield) from the UKRI (Economic and Social Research Council).
She is a member of the British Sociological Association, the British Society of Gerontology, the UK Social Policy Association, and the Labour Party. As Director of CIRCLE (Centre for International Research on Care, Labour and Equalities) she is also a member of the international NGO Eurocarers. </span></em></p>Care workers, care recipients, think tanks and parliament itself agree that social care reform is urgently needed. But this plan’s lack of detail and insufficient funding suggest that it a ways off.Sue Yeandle, Professor of Sociology, University of SheffieldLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1724312021-11-25T17:57:06Z2021-11-25T17:57:06ZSocial care cap: how the new system will work and why it’s unfair – an expert explains<figure><img src="https://images.theconversation.com/files/433463/original/file-20211123-23-1pnc5t0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">With means-tested support, those who are less well-off will end up losing more of their assets to pay for their care.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-home-carer-supporting-old-woman-1815235466">pikselstock | Shutterstock</a></span></figcaption></figure><p>Boris Johnson’s proposed new cap on social care has moved a step closer to reality after a majority of MPs <a href="https://www.bbc.co.uk/news/uk-politics-59365729">voted in favour</a> of it in parliament. The cap, which is part of a wider <a href="https://theconversation.com/social-care-reform-heres-why-this-tax-rise-isnt-just-unfair-on-young-people-167473">set of plans</a> to reform social care, is designed to address the fact that some people end up losing their homes and savings because of what they have to pay for care.</p>
<p>Under the current system, one in ten people aged 65 in England will incur social-care costs of £100,000 or more over <a href="https://webarchive.nationalarchives.gov.uk/ukgwa/20130221121534/http:/www.dilnotcommission.dh.gov.uk/our-report">their lifetimes</a>. From 2023, the government <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care/adult-social-care-charging-reform-further-details">proposes</a> that £86,000 will be the maximum that anyone has to spend on care costs. </p>
<p>Unfortunately, however, the proposals come with major drawbacks. How the cap is reached is not as straightforward as it initially appears. And <a href="https://www.theguardian.com/society/2021/nov/17/the-uk-social-care-cap-how-will-it-work-and-is-it-fair">above all</a>, the proposed changes will not help many of the less well-off to the same extent as it helps the wealthy. Yet again, the government is being criticised for implementing a manifesto pledge while, at the same time, chipping away at its declared aim of “<a href="https://theconversation.com/what-actually-is-levelling-up-what-we-know-about-boris-johnsons-agenda-and-what-we-dont-164886">levelling up</a>” the people and regions that have been left behind.</p>
<figure class="align-center ">
<img alt="An elderly couple walk down a leafy lane." src="https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/433446/original/file-20211123-21-la7ik0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The proposed cap to social-care costs could perversely result in poorer elderly people losing their homes.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/PpZasS086os">Visual Stories | Unsplash</a>, <a class="license" href="http://artlibre.org/licence/lal/en">FAL</a></span>
</figcaption>
</figure>
<h2>Lifetime expenditure</h2>
<p>The proposals for the new cap on social care were originally put forward by the <a href="https://www.ageuk.org.uk/information-advice/care/dilnot-commission/#proposals">Dilnot commission</a> in 2011, which had been set up by the Cameron government to look into this area. The cap relates to the amount that anyone in England spends on social care over their lifetime.</p>
<p>Under the plan, the cap is to be means tested. Anyone with over £100,000 in assets (the upper capital limit) will be required to fund their social care costs until they have spent £86,000, at which point the local authority will take over. Those with less than £20,000 in assets (the lower capital limit) will have their social-care costs fully paid for by their local authority. </p>
<p>Those whose wealth lies somewhere in between those capital limits will pay £1 weekly – a so-called tariff income – for every £250 of their wealth. For example, for someone with £50,000 in assets, that would work out to £200 a week, or £10,400 for the year. But since any one year’s contribution is capped at 20% of a person’s wealth, this would be reduced to £10,000. Their chargeable wealth the following year would be £40,000 (£50,000 less £10,000). And so on until the lower capital limit of £20,000 is reached. </p>
<p>Under these proposals, people will also be required to use their income – and, if necessary, wealth – to pay for non-care costs relating to accommodation and food. These costs will be capped at £200 per week for all but are not included as contributing to the social-care cap. </p>
<p>Each person’s local authority is to be responsible for determining the financial plan for their care. It will calculate when the social-care cap will be reached and the person no longer has to contribute. </p>
<figure class="align-center ">
<img alt="A blind man walks with a guide dog." src="https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=451&fit=crop&dpr=1 600w, https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=451&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=451&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/433461/original/file-20211123-22-r1bcuc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Not all costs incurred in the context of adult social care will be covered by the cap.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/dQqO28G0kE4">Matt Seymour on Unsplash</a>, <a class="license" href="http://artlibre.org/licence/lal/en">FAL</a></span>
</figcaption>
</figure>
<h2>Built-in inequality</h2>
<p>To be sure, the new system will protect those currently paying substantial care costs from the fear of not knowing how much they will have to pay. This marks an improvement as there is currently no insurance policy which offers protection against such uncertainty.</p>
<p>However, calculating when the £86,000 cap kicks in will be complicated. Wealth, income and benefits all need to be taken into account anew, each year. </p>
<p>But the bigger issue is that people in parts of the country where houses are valued in the tens of thousands rather than the hundreds of thousands will suffer relatively more, with the possibility of losing a maximum of 80% of their savings and still potentially having to sell their house. </p>
<p>Under the current system, two people with wealth of £200,000 and £100,000 would lose a maximum of 93% and 86% of their wealth respectively. This explains why there has been pressure for a cap. </p>
<p>However, the way the new system has been devised <a href="https://www.health.org.uk/news-and-comment/news/last-minute-changes-to-social-care-reforms-are-a-step-in-the-wrong-direction">means that</a> while the person with £200,000 will now lose much less of their wealth (43%), the person with £100,000 would still lose almost everything (80%). This is clearly unfair. </p>
<p>It means that the less well-off – but not the destitute – will suffer the most. It’s the same problem with the new health and social care levy with which the government aims to fund social-care reform. The levy has <a href="https://theconversation.com/social-care-reform-heres-why-this-tax-rise-isnt-just-unfair-on-young-people-167473">been derided</a> for not including any kind of wealth or income tax but instead being linked to a rise in national insurance contributions. </p>
<p>Hard-working parents who, through no fault of their own, have illnesses which require substantial care will still see their assets dwindle almost to nothing and will be unable to help their children as intended. The cap on social-care costs thus works out, effectively, as an inheritance tax for these families. </p>
<p>On the other hand, someone with a £1 million house is vanishingly unlikely to lose it to care costs. They can even pass that home on to their children completely free of inheritance tax of 40%, because in 2017 the UK government introduced an extra nil-rate band for married couples and registered civil partners to pass on their main residence and assets up to <a href="https://www.brewin.co.uk/insights/inheritance-tax-do-you-qualify-for-the-new-1m-allowance">£1 million tax free</a> (compared to a nil-rate band of £325,000 for a single person) to their children. </p>
<h2>Dwindling assets</h2>
<p>The cap on costs is also not quite what it seems. Under the new rules, people in care –- whether at home or in a care home –- will be able to make voluntary top-up payments to cover improvements to their care, such as a premium room in a care home. This might cause difficulties when the cap is reached, for example if the person does not wish to be relocated to a home which provides the basic care as specified by the local authority but not the upgraded care they or their family have sought out. To continue receiving this care, they would have to pay for it themselves. </p>
<p>Equally, the costs of care used in council calculations will only be <a href="https://www.communitycare.co.uk/2021/09/22/quick-guide-to-the-cap-on-care-costs/">based on</a> what the local authority itself would pay for that level of care. In many cases that will be less than the amount that individual self-funders currently pay –- so again, people could end up paying beyond the cap.</p>
<p>The cost of the cap, which will be felt by tens of thousands of people, is only for the relatively modest saving in government revenue of <a href="https://news.sky.com/story/social-care-cap-why-the-governments-plan-is-worrying-some-tory-mps-as-key-vote-looms-12475481">£900 million</a>. This is a small figure, compared with the <a href="https://theconversation.com/social-care-reform-why-boris-johnsons-plan-wont-fix-the-crisis-expert-view-167472">£12 billion</a> the health and social care levy is set to bring in.</p><img src="https://counter.theconversation.com/content/172431/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janette Rutterford does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The case for introducing a limit on how much people pay for their own care is clear. Figuring out how to calculate that cap, though, is complicated.Janette Rutterford, Emeritus Professor of Finance and Financial History, The Open UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1697802021-11-19T12:55:03Z2021-11-19T12:55:03ZSocial care reform: free online event on what isn’t working and how to fix it<p>Boris Johnson’s September announcement of a plan to fund social care reform and NHS recovery in England was <a href="https://theconversation.com/social-care-reform-heres-why-this-tax-rise-isnt-just-unfair-on-young-people-167473">long-awaited</a>, if <a href="https://theconversation.com/social-care-reform-why-boris-johnsons-plan-wont-fix-the-crisis-expert-view-167472">not applauded</a>. Critics question the extent to which the new health and social care levy the government proposes will be fair or sufficient. The <a href="https://www.bbc.co.uk/news/uk-politics-59323311">newly announced cap</a> on personal care costs has only added fire to their fuel.</p>
<p>The health secretary, Sajid Javid, is <a href="https://theguardian.com/society/2021/oct/10/sajid-javid-radical-plan-merge-social-care-health-england-nhs-white-paper-reform">reportedly</a> now considering plans to merge health and social care into a single organisation, funded by a single budget. Historical precedents suggest, though, that social care will lose out. As public policy expert Catherine Needham has <a href="https://theconversation.com/social-care-reform-why-boris-johnsons-plan-wont-fix-the-crisis-expert-view-167472">pointed out</a>: “Of the £36 billion that will be raised by this levy, only £5.4 billion will go to social care, and half of that will pay for the new care cap rather than address any of the existing strains in the system.”</p>
<p>The pandemic has wreaked havoc on the system. The <a href="https://theconversation.com/care-homes-have-long-been-neglected-the-pandemic-has-shown-us-how-bad-things-are-137458">devastating numbers</a> of COVID-related deaths in care homes have had significant negative impacts on the <a href="https://covidandsociety.com/addressing-mental-health-wellbeing-care-home-residents-staff-impacts-responses/">mental health and wellbeing</a> of residents. </p>
<p>The sector’s workforce, too, has been sorely tested. As the National Care Association <a href="https://www.thelondoneconomic.com/politics/brexit-is-sparking-an-adult-social-care-crisis-in-britain-experts-warn-287429/">underlines</a>, even before the pandemic hit there were upwards of 124,000 vacancies in the sector. </p>
<p>Low wages, COVID stresses and an inhospitable immigration environment have since led to a staffing crisis. Faced with a reported <a href="https://news.sky.com/story/covid-19-adult-social-care-job-vacancies-higher-than-before-pandemic-report-finds-12432567">8.2%</a> of places unfilled, recruiters describe the social care workforce as <a href="https://www.theguardian.com/society/2021/sep/12/care-sector-staff-are-quitting-flu-is-coming-and-the-elderly-are-fearful">“completely falling to pieces”</a>. </p>
<p>Among the reasons for these shortages are Brexit and other Home Office decisions around migrant workers. But on a more fundamental level, vacancies go unfilled because social care is not seen as a viable career option. </p>
<p>This, to many experts’ minds, speaks to the most pressing question facing not just those who work in adult social care, but society at large. Contrary to the narrow financial debate to which the government often reduces social care, campaigners, including the <a href="https://socialcarefuture.blog/">Social Care Futures</a> project, are calling for a societal reckoning with what social care actually is and what we want it to be. </p>
<p>Providing support for the elderly and those with disabilities is not just a cost but an investment in social infrastructure. After all, the sector contributes <a href="https://www.skillsforcare.org.uk/About/News/News-Archive/Adult-social-care-contributes-50.3-billion-to-English-economy-our-report-finds.aspx">£50.3 billion</a> to the English economy. In that light, prioritising wellbeing for those in need and their carers is crucial, as is working to devise a <a href="https://www.ucl.ac.uk/steapp/sites/steapp/files/thinking_systems_2021_mulgan.pdf">better, data-led care system</a>.</p>
<p>In order to understand what fixing social care in England actually looks like, The Conversation is running a webinar on December 2, 5:30PM GMT, the third in a series in partnership with the <a href="https://covidandsociety.com/about-ippo/">International Public Policy Observatory</a> (IPPO).</p>
<p>The webinar will bring academics together to discuss the extent to which the pandemic has worsened the crisis the care sector faces, and what needs to be done now to ensure better policies and outcomes as we recover from COVID.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=333&fit=crop&dpr=1 600w, https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=333&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=333&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=418&fit=crop&dpr=1 754w, https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=418&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/434182/original/file-20211126-17-s6szf1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=418&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p>Commissioning editor Dale Berning Sawa will host the event, joined by:</p>
<ul>
<li><p>Liz Jones, policy director, the National Care Forum;</p></li>
<li><p>Sir Geoff Mulgan, IPPO project lead and professor of collective intelligence, public policy and social innovation at UCL;</p></li>
<li><p>Jon Glasby, professor of health and social care at the University of Birmingham;</p></li>
<li><p>Isaac Samuels, freelance co-production advisor.</p></li>
</ul>
<p>The webinar will be free to watch directly via these links on <a href="https://www.facebook.com/148546898646992/posts/1994619674039696/">Facebook</a>, <a href="https://www.youtube.com/watch?v=rqfw_fqQc74&ab_channel=TheConversation">YouTube</a> and on <a href="https://twitter.com/ConversationUK">Twitter</a>. No registration is needed. </p>
<p><em>IPPO was commissioned by the Economic and Social Research Council in response to COVID-19, to develop a knowledge system that is quick and responsive while also grounded in the latest and most robust global evidence. This webinar forms part of IPPO’s ongoing work on COVID-19’s unequal impacts on society, and how policymakers in all parts of the UK can best respond to this. To find out more about this groundbreaking project, sign up for the newsletter <a href="https://covidandsociety.us1.list-manage.com/subscribe?u=13ed825f182f448af27d7b228&id=cbf3a8e0e3">here</a>.</em></p><img src="https://counter.theconversation.com/content/169780/count.gif" alt="The Conversation" width="1" height="1" />
Social care has long been the healthcare system’s poor cousin. Will the UK government’s new plans to reform the system succeed where others have not?Dale Berning Sawa, Commissioning Editor, Societies, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677562021-09-14T14:07:47Z2021-09-14T14:07:47ZNew laws in England will leave 16-year-olds living alone<p>The English system for accommodating children in care is <a href="https://www.gov.uk/cma-cases/childrens-social-care-study">broken</a>. Demand outstrips supply and the uneven spread of children’s homes across the country, especially for children requiring specialist care, forces councils to increasingly rely on private, <a href="https://socialcareinspection.blog.gov.uk/2019/07/08/unregistered-and-unregulated-provision-whats-the-difference/">unregulated</a> accommodation. </p>
<p>This situation is about to get worse. The law around how teenagers in care are housed has changed. On September 9, a piece of legislation, entitled the Care Planning, Placement and Case Review (England) (Amendment) Regulations 2021, <a href="https://www.legislation.gov.uk/uksi/2021/161/introduction/made">came into force</a>. It states that councils can now place children aged 16 and 17 into unregulated accommodation. Also called independent and semi-independent housing, this is non-care accomodation. The occupants, who are legally still children, only receive support, not care, as they would in foster care or a children’s home.</p>
<p>Typically, this sees young people aged 16-25 sharing communal facilities, while having their own room and bathroom. They are responsible for meeting their own health needs. They have full control of their finances. They are permitted to stay away overnight. And, crucially, there is no direct supervision provided by adults. Any support that is provided by adult workers aims to help them to live independently.</p>
<p>Approximately <a href="https://www.gov.uk/government/publications/looked-after-children-in-independent-or-semi-independent-placements+&cd=1&hl=en&ct=clnk&gl=uk">6,000</a> over-16s –- boys and unaccompanied <a href="https://theconversation.com/when-unaccompanied-young-asylum-seekers-turn-18-many-face-an-immigration-cliff-edge-106734">asylum-seeking children</a> in particular – currently live this type of housing. And for some, this is the best choice. It fosters independence. </p>
<figure class="align-center ">
<img alt="A graphic showing the number of children living independently or in unregulated accommodation between 2010 and 2019." src="https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=445&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=445&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=445&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=559&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=559&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420634/original/file-20210912-13-gn8ft3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=559&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The number of children in England living independently or in unregulated accommodation has risen substantially since 2010.</span>
<span class="attribution"><a class="source" href="https://www.gov.uk/government/publications/looked-after-children-in-independent-or-semi-independent-placements">SSDA903 / Department for Education</a>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>In many cases, however, it is unsuitable. A <a href="https://www.bbc.co.uk/programmes/p09vks65">freedom of information request</a> saw the department for education reveal that, between April 2018 and September 2020, ten children died while living in supported accommodation, of whom half took their own lives.</p>
<p>While the reasons for these deaths will be complex, the children’s rights organisation <a href="https://article39.org.uk/keepcaringforchildrenupto18/">Article 39</a> asks if things may have been different had their housing situation provided them with more care.</p>
<p>This change in legislation is likely to have disastrous consequences. Here are four reasons why.</p>
<h2>It denies teenagers their legal status as children</h2>
<p>Both the <a href="https://www.ohchr.org/EN/ProfessionalInterest/Pages/CRC.aspx">UN convention</a> on the rights of the child and the <a href="https://www.legislation.gov.uk/ukpga/1989/41/contents">Children’s Act</a> in England define a child as a person under the age of 18. </p>
<p>However, in some <a href="https://www.justforkidslaw.org/what-we-do/fighting-progress/monitoring-rights/state-childrens-rights">instances</a> the way the government treats children appears to <a href="https://www.tandfonline.com/doi/full/10.1080/1369183X.2017.1417027">disregard</a> their <a href="https://www.theguardian.com/society/2021/feb/16/watchdog-accuse-uk-ministers-institutional-bias-against-children-anne-longfield">vulnerable status</a>. </p>
<p>When the state becomes the parent, it has a duty to nurture and care so that children reach their full potential. For 16 and 17-year-olds, this new legislation seems counter intuitive. By contrast, children who live with their families leave home, <a href="https://www.becomecharity.org.uk/care-the-facts/about-the-care-system/">on average</a>, at around 23. </p>
<p><a href="https://coramvoice.org.uk/wp-content/uploads/2021/01/Care-Leaver-Rapid-Review-24.10.17-final-proof-2.pdf">Research</a> shows that for some, the move to non-care placements is too much, too soon. They feel ill-prepared to move out, both practically and emotionally. Care leavers <a href="https://www.sciencedirect.com/science/article/pii/S0190740920322519">have been found</a> to want a safe space to practice their independence, without worrying that they might suffer consequences such as homelessness or failing in education if they make mistakes. </p>
<h2>It undermines their health and wellbeing</h2>
<p>We <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijsw.12317?casa_token=2yF4xKB2bPMAAAAA%3Axe5hevLzJ58W-FoYRwAPiMqm4jKdIhQGvmIwdJx8IOPCx53bMW3zIWspE1RBNL6QyVuhogof0MxmiQ8">know</a> that children in care are more likely to have <a href="https://theconversation.com/revealed-health-prospects-of-children-in-care-look-worse-than-for-anyone-else-83270">long-term health conditions</a>, which last well into <a href="https://www.ucl.ac.uk/news/2020/jul/children-care-suffer-poor-health-decades">adulthood</a>. Levels of mental health problems are high among these children too. </p>
<p>However, as children in care <a href="https://theconversation.com/care-leavers-trying-to-access-childhood-records-is-distressing-and-dehumanising-124381">transition</a> to <a href="https://www.sciencedirect.com/science/article/pii/S1751722220300378?casa_token=ZJG451xc8ZYAAAAA:CUjXUAHrFQffdP43b9m_hwJpRYZeBmIFy4Mb4jPYeAtjhGmltICfXbDNgutgO3cvvuqtgcBHMA">independence</a> – between the ages of 16 and 18 - they have been found to often not engage with the support services that could help them. There is a distinct possibility that by removing the care that is provided at 15, health appointments can be missed and conditions worsen or go untreated. </p>
<p>As <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4924050/">my research</a> and <a href="https://journals.sagepub.com/doi/full/10.1177/0308575918823432">other studies</a> have found, key workers in children’s homes go to great lengths to improve children’s wellbeing and bolster their ability to look after themselves. Many fear this good work will be undone if they are abruptly left to fend for themselves. </p>
<h2>It makes them vulnerable to exploitation</h2>
<p>At its worst, non-care accommodation places <a href="https://theconversation.com/children-transitioning-from-care-to-adult-life-are-being-badly-let-down-and-falling-prey-to-criminal-gangs-145939">vulnerable children</a> with other, often older individuals who have a range of complex problems. This has been found to put children at risk of involvement in <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/spol.12600">exploitation</a> and organised crime, including county lines drug dealing. It also puts them at greater risk of <a href="https://commonslibrary.parliament.uk/research-briefings/cbp-7560/">going missing</a> for long periods. </p>
<p>Young people themselves cite the lack of a place to call home, instability, uncertainty and the sense of <a href="https://academic.oup.com/bjsw/article/46/7/2137/2770735?login=true">powerlessness</a> leading – directly or indirectly – to their being exploited. They consider themselves different, and as having to manage without the same kind of care and attention that other children receive.</p>
<h2>It threatens their educational outcomes</h2>
<p>By law, children must continue their <a href="https://theconversation.com/children-in-care-are-falling-behind-in-literacy-and-numeracy-but-the-problem-is-far-bigger-than-that-49427">education</a> or training until the age of 18. However, this new care legislation effectively means the state considers that teenagers taking their GCSEs can fend for themselves. </p>
<p>Generally, children in care do less well in <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/794535/Main_Text_Outcomes_for_CLA_by_LAs_2018.pdf">education</a>. A recent <a href="https://www.togethertrust.org.uk/news/new-research-wheres-care">report</a> by the Together Trust, highlighted that over 3,000 children aged 16 and 17 were out of education, employment or training – thus categorised as <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/679535/Characteristics_of_young_people_who_are_long_term_NEET.pdf">NEETs</a> – for all or some of their time in unregulated accommodation. </p>
<p>Conversely, <a href="https://ajph.aphapublications.org/doi/full/10.2105/AJPH.2018.304587">research</a> shows that the presence of supportive adults promotes positive educational outcomes, particularly for children who <a href="https://pediatrics.aappublications.org/content/140/3/e20170503">spend longer</a> in care. This would then most apply to those 16- and 17-year-olds who are transitioning out of the care system.</p>
<p>These children deserve stepping stones to independence, not a cliff edge. The state – their de facto parents – should never leave them without the supervision and support that would ensure they are safeguarded against harm. Would our politicians think this good enough for their own children?</p><img src="https://counter.theconversation.com/content/167756/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lisa Huddlestone does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Teenagers transitioning from long-term care to independent adulthood need to be looked after. Their health, wellbeing, education and their safety are at riskLisa Huddlestone, Research Fellow in Health Sciences, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1675742021-09-08T16:48:53Z2021-09-08T16:48:53ZSocial care reform: lifetime cap on costs may only partially protect assets<p>The costs of care in old age can be scarily high and difficult to plan for, particularly if it becomes necessary to move into a care home. It’s estimated that while a quarter of older people might <a href="https://webarchive.nationalarchives.gov.uk/ukgwa/20130221121534/http:/www.dilnotcommission.dh.gov.uk/our-report">escape the need</a> for care altogether, one in seven could incur costs of <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care">more than £100,000</a>. </p>
<p>A proposed lifetime cap, announced as part of the recently announced UK government’s social care reform plan, would theoretically ease the burden for many families. But it may not be the cure-all it seems.</p>
<p>The average cost of a place in a residential care home in England is around <a href="https://www.which.co.uk/later-life-care/financing-care/care-home-finance/care-home-fees-akdbv8k3kwln">£35,400 a year</a>, but in London and south-east England, fees can <a href="https://www.which.co.uk/later-life-care/financing-care/cost-of-care-and-eligibility-checker/">easily top £65,000</a>. </p>
<p>Under current rules in England, a care home resident has to meet these costs out of their income and assets until their remaining assets <a href="https://www.gov.uk/government/publications/social-care-charging-for-local-authorities-2020-to-2021">drop to £23,250</a> at which point means-tested help from the state would kick in. This can virtually wipe out the financial assets that people have built up during their lifetime. It can also result in people having to sell their homes, unless a partner or other specified dependant will continue living there (in which case the home is excluded from assets for the purpose of the means test).</p>
<p>The proposed lifetime <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care">cap of £86,000</a> is <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care">designed to</a> “protect individuals and families against unpredictable and potentially catastrophic care costs”, in the government’s words.</p>
<p>It is a welcome move to provide some protection against this social care lottery – although funding it through an <a href="https://www.bbc.co.uk/news/uk-politics-58436009">increase in national insurance</a> is contentious. It will finally bring into effect the recommendations of the 2011 Dilnot commission to create such a cap. These recommendations were legislated for in England in the <a href="https://www.legislation.gov.uk/ukpga/2014/23/section/15/enacted">Care Act 2014</a> but not implemented. </p>
<p>However, the government will need to carefully manage public expectations because the lifetime cap does not necessarily mean that financial assets will be protected or that people needing care will not have to sell their home, as suggested. The details of how the cap will work are yet to be announced and may deviate from the Care Act 2014. Even so, many people moving into a care home may still have to pay thousands of pounds out of their own assets for two main reasons.</p>
<p>First, under current rules which are expected to continue, individual local authorities set the maximum amount that they will pay towards such fees. These amounts are notoriously low, with care homes charging self-funding residents <a href="https://www.ageuk.org.uk/latest-press/articles/2020/06/care-home-residents-are-being-clobbered-with-a-coronavirus-bill/">around 40% more</a> to subsidise local authority-funded residents. It is these local authority rates that are likely to be the basis of what counts towards the lifetime cap. </p>
<p>If a person cannot find a suitable care home with costs equal to the local authority contribution, or chooses a more expensive option, the extra amount paid will not count towards the cap. We await to see whether the extra funding for social care announced in the reform will result in local authorities paying a more economically viable rate to care homes. </p>
<h2>Costs not covered</h2>
<p>The second reason is that the cap will not cover the daily living costs component of care home fees, such as food and accommodation. There is little transparency over what these costs are, and so they have to be estimated. </p>
<p>Everyone needs to meet these costs wherever they live, putting care home residents on an equal footing with people who receive care in their own homes. Care homes typically do not break down their bills into care and residential components, so the residential part may be considerably more than a person living in their own home would spend.</p>
<p>The Care Act 2014 tackles this issue by saying that the government will set a standard amount for daily living costs. Crucial, then, is what that deemed amount turns out to be. As that 2014 policy was being debated, the <a href="https://www.gov.uk/government/consultations/caring-for-our-future-implementing-funding-reform">government proposed</a> setting deemed residential costs at £12,000 a year, at that time <a href="https://commonslibrary.parliament.uk/research-briefings/sn05649/">about double</a> the basic state pension. </p>
<p>So how might this work in practice? Let’s look at an example. Jo, who does not qualify for means-tested help with care costs, moves into a residential care home, paying £35,400 a year. The maximum the local authority would pay is only £29,500. Moreover, from this amount, deemed daily living costs of £12,000 would be deducted. This means the care costs that will count towards the lifetime cap are just £17,500 a year (£29,500 - £12,000). </p>
<p>The remaining £17,900 (£35,400 - £17,500) is outside the cap. If the total cost of £35,400 were included, Jo would have reached the lifetime cap of £86,000 in less than three years. But with just £17,500 a year counting towards the cap, it instead takes nearly five years before the cap is reached and the state takes over paying any of Jo’s care costs.</p>
<p>Alongside the new proposals, Health Secretary Sajid Javid <a href="https://www.bbc.co.uk/sounds/play/m000zdt9">has suggested</a> that the deemed residential costs should be affordable out of the state pension, though this seems debatable. For people who reached state pension age before April 6 2016, the full basic state pension is just over £7,100 a year, though they might also get some secondary state pension. For those reaching state pension age on or after that date, the full new state pension is just over £9,300 a year. </p>
<p>Anyone whose income is lower than the residential cost limit will have to dip into their assets to make good on the shortfall, unless their income and assets are sufficiently low to qualify them for means-tested help with care costs. As is the case under current rules, those who do not own a home and just have financial assets are particularly vulnerable to seeing the bulk of those assets wiped out.</p>
<p>So while it is true that the lifetime cap (together with more generous <a href="https://www.gov.uk/government/publications/build-back-better-our-plan-for-health-and-social-care">means-testing limits</a>) will slow the pace at which assets are used, it does not guarantee that assets beyond £86,000 will be preserved. The government needs to be careful not to over-promise what the changes will deliver.</p><img src="https://counter.theconversation.com/content/167574/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonquil Lowe does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Key loopholes in the proposed cap on social care spending mean all assets won’t necessarily be protected.Jonquil Lowe, Senior Lecturer in Economics and Personal Finance, The Open UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1674722021-09-07T17:36:40Z2021-09-07T17:36:40ZSocial care reform: why Boris Johnson’s plan won’t fix the crisis – expert view<figure><img src="https://images.theconversation.com/files/419850/original/file-20210907-21-1d4vvqv.jpg?ixlib=rb-1.1.0&rect=143%2C71%2C5847%2C3916&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">PA Images /Alamy </span></span></figcaption></figure><p>Boris Johnson has <a href="https://www.theguardian.com/politics/2021/sep/07/boris-johnson-unveils-12bn-a-year-tax-rise-to-pay-for-nhs-and-social-care">unveiled plans</a> for a £12 billion-a-year tax rise from April 2022, to fund <a href="https://theconversation.com/rishi-sunaks-fight-to-raise-taxes-to-reform-social-care-is-nothing-compared-to-financial-battles-ahead-167399">social care reform</a> in England and to tackle the NHS’s <a href="https://theconversation.com/coronavirus-crisis-is-a-turning-point-for-the-nhs-for-good-or-bad-we-just-dont-know-yet-135778">COVID-induced backlog</a> of cases. </p>
<p>Demand for care - from short-term needs to long-term support – is <a href="https://www.kingsfund.org.uk/publications/social-care-360">rising</a> and levels of <a href="https://www.ageuk.org.uk/latest-press/articles/2019/november/the-number-of-older-people-with-some-unmet-need-for-care-now-stands-at-1.5-million/">unmet need</a> are soaring. Social care needs <a href="https://theconversation.com/social-care-crisis-is-letting-down-professional-carers-too-118376">urgent investment</a>. </p>
<p>The four nations of the UK each have their <a href="http://circle.group.shef.ac.uk/2018/09/20/anaturalexperiment/">own care systems</a>. In England, requests for social care have gone up 6% in the last five years but there has been a <a href="https://www.kingsfund.org.uk/publications/social-care-360">decrease</a> in people getting support. Around 14,000 fewer people have received the help they need. </p>
<p>The announcement of extra funding intended to fill that gap should be heartening. However, the money the government is seeking is set to finance not only a social-care system reform but also an NHS rescue plan. Getting back to pre-pandemic level of NHS service alone is likely to cost almost <a href="https://www.health.org.uk/news-and-comment/news/almost-17bn-needed-to-clear-backlog-and-treat-expected-rise-in-patients?utm_campaign=527654_PRESS%20RELEASE%20Comment%20on%20Health%20Foundation%20funding%20analysis&utm_medium=email&utm_source=NHS%20Confederation&dm_i=6OI9,BB52,282IDV,1D0X8,1">£17 billion</a>. Critics fear that the new levy will be used up within the NHS with little left to spend on improving social care. The research I have done on <a href="https://www.birmingham.ac.uk/documents/college-social-sciences/social-policy/publications/shifting-shapes-policy-brief.pdf">care markets</a> and <a href="http://circle.group.shef.ac.uk/sustainable-care/">sustainable care systems</a> highlight that these new proposals are unlikely to deliver what we so urgently need. </p>
<h2>A complex system</h2>
<p>Social care, which provides long-term care for people with a disability and age-related frailty, is a hugely complex system. It covers residential care, home care, day services and a wide range of community supports. </p>
<p>In the UK, most of these are provided by the private sector, in a diverse <a href="https://www.birmingham.ac.uk/documents/college-social-sciences/social-policy/hsmc/research/market-shaping-and-personalisation-social-care.pdf">marketplace</a> of thousands of providers and community groups. People currently pay for their own care if their assets exceed a certain level (£23,500 in England), otherwise care is purchased for them by their local council. </p>
<p>People are living much longer with multiple conditions that need support from the care system. Although much of the conversation about care focuses on older people, <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/986770/Queen_s_Speech_2021_-_Background_Briefing_Notes..pdf">half of spending</a> is actually on working-age people with disabilities. Families also provide a huge amount of <a href="https://www.carersuk.org/for-professionals/policy/policy-library/unseen-and-undervalued-the-value-of-unpaid-care-provided-to-date-during-the-covid-19-pandemic">informal care and support</a>. </p>
<h2>Current proposals</h2>
<p>Boris Johnson has been promising reform to social care <a href="http://ssrg.org.uk/wp-content/uploads/2018/02/Powell-Hall.pdf">since he took office</a> in 2019 and, finally, he has announced what that will be. The plans involve a national insurance rise for what the government is labelling a health and social care levy. They also include a limit of £86,000 to how much people will have to pay for care in their lifetime. </p>
<p>At the moment there is no maximum amount that a person can pay for care. For some people with long-term conditions like dementia, the costs run into hundreds of thousands of pounds. </p>
<p>There is a real need for new money in the system. But of the £36 billion that will be raised by this levy, only £5.4 billion will go to social care, and half of that will pay for the new care cap rather than address any of the existing strains in the system. </p>
<p>Proposals to introduce a cap on care spending are welcome. But we’ve had a cap in law before. It was part of the <a href="https://www.legislation.gov.uk/ukpga/2014/23/contents/enacted">Care Act 2014</a> and then abandoned because of concerns about the viability of implementation. </p>
<p>The spending of self-funders (a relatively <a href="https://www.cambridge.org/core/journals/social-policy-and-society/article/selffunders-still-bystanders-in-the-english-social-care-market/D220BE172CFE378F3B07B339B7AB1F59">invisible and hard to research</a> group) would need to be monitored by local authorities so that it was clear when the cap had been reached. We don’t yet have systems in place to do that. The current proposals (a cap on spending with a sliding scale of contributions for people with assets of £20,000 to £100,000), appear to be even more complex that those attempted in 2014. </p>
<p>The new proposals also do nothing to address low pay for the 1.5 million people working in the care sector. They won’t improve the range, quality or adequacy of social care, a system that many people say is about meeting basic needs rather than enhancing wellbeing or allowing people to flourish. </p>
<p>For those articulating a <a href="https://socialcarefuture.blog/">more ambitious account</a> of what social care reform could achieve, there is little to celebrate in the new announcements. </p>
<p>If the proposals make it into law – and there is a long road ahead with potential hostility from all sides – then they will apply to people accessing care from 2023. Having paid towards a health and social care levy, many of these people will have high expectations of what they will get from social care. If the money goes to the NHS, leaving social care mired in crisis, then there may be political costs to Johnson beyond his current headache of a broken manifesto promise.</p><img src="https://counter.theconversation.com/content/167472/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Catherine Needham has received funding from the Economic and Social Research Council and the National Institute for Health Research. She is a member of the Labour Party</span></em></p>The government proposes to fix social care and rescue the NHS in one go. The levy it proposes risks only scratching the surfaceCatherine Needham, Professor of Public Policy and Public Management, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1628762021-06-17T18:04:31Z2021-06-17T18:04:31ZShould COVID vaccines be compulsory for care home staff? Experts debate<p>The UK government <a href="https://www.bbc.co.uk/news/uk-57492264">has announced</a> that COVID-19 vaccination will become mandatory for staff working in care homes for older people in England. Staff <a href="https://www.bbc.co.uk/news/uk-57492264">will be given 16 weeks</a> to get the vaccine. If they don’t get the jab, they will be redeployed from frontline care or lose their job.</p>
<p>Mandating vaccination would increase vaccine uptake in care home workers, but it would be a significant intrusion into individual freedom. Is it ethically justifiable?</p>
<h2>Yes – Professor Dominic Wilkinson</h2>
<p>In the early phase of the pandemic, some of the most medically vulnerable people ended up catching coronavirus from those caring for them; <a href="https://www.theguardian.com/society/2021/mar/26/40600-people-likely-caught-covid-while-hospital-inpatients-in-england">40,000 patients in England</a> are said to have caught COVID while in hospital. Some patients and care home residents died from infections that they caught from their caregivers. We must do everything possible to avoid repeating this tragic and distressing situation.</p>
<p>First, we should ensure that all those who are at a high risk of dying from COVID have access to the vaccine. <a href="https://www.england.nhs.uk/statistics/statistical-work-areas/covid-19-vaccinations/">About 10%</a> of older adult care home residents have still not had a second dose of the vaccine. </p>
<p>Second, those who work in the frontline with vulnerable high-risk patients have an ethical obligation to take all reasonable measures to prevent the spread of the virus to those they are caring for. They must follow the guidance on things like hand washing and PPE. They should take part in lateral flow testing schemes. And they should be vaccinated. </p>
<p><a href="https://jme.bmj.com/content/medethics/early/2021/04/28/medethics-2020-107175.full.pdf">Mandating vaccination can be ethical</a> if it is both necessary and proportionate. A mandate is not necessary if there are less intrusive means of effectively increasing uptake, such as persuasion and incentives. The problem is that less intrusive means may be much less effective. </p>
<p>Persuasion has so far failed. There is <a href="https://pubmed.ncbi.nlm.nih.gov/26619125/">strong evidence</a> to suggest that vaccine mandates are the most effective way to increase uptake. </p>
<p>A mandate could be proportionate if the public health benefit of increasing uptake among staff would outweigh the harms. Given the considerable vulnerability of care home residents, this seems to be the case. Care home residents can’t choose who cares for them. Some remain only partly protected after vaccination. The risks of vaccination for workers are exceptionally low. </p>
<p>However, if vaccines are made mandatory for care home workers (or healthcare workers), they should be able to choose from available vaccines. Every effort possible should be made to address any concerns that they have about the vaccines.
A <a href="https://jme.bmj.com/content/medethics/early/2021/04/28/medethics-2020-107175.full.pdf">conditional vaccination policy</a> would be ethical. </p>
<p>Care home workers – and NHS staff – who have not had the COVID vaccine should be redeployed to areas other than frontline care. In the absence of a medical exemption, COVID vaccination should be a condition of employment in the same way that hepatitis B vaccination is currently for some health professionals.</p>
<h2>No – Professor Julian Savulescu</h2>
<p>Mandatory vaccination policies <a href="https://jme.bmj.com/content/47/2/78">can sometimes be ethical</a>. But the proposal to make vaccination mandatory for care home workers is muddle-headed. </p>
<p>There are rare but serious risks of vaccination: <a href="https://www.ema.europa.eu/en/news/covid-19-vaccine-astrazeneca-benefits-still-outweigh-risks-despite-possible-link-rare-blood-clots">blood clots for AstraZeneca</a> and <a href="https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/myocarditis.html">probable myocarditis in Pfizer</a>. COVID-19 deaths are predominantly in the elderly, while rare side-effects are mostly in the young. </p>
<p>For most, these small risks won’t change the risk-benefit ratio. But for some, the risk-benefit ratio looks very different. </p>
<p>Imagine a 20-year-old care worker on a zero-hours contract, like 24% of her colleagues, who worked through the pandemic and gained natural immunity from becoming infected. She, and those in her care, have little to gain from her undergoing vaccination to gain additional immunity. </p>
<p>A <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00675-9/fulltext#seccestitle130">Public Health England study</a> compared vaccine and natural immunity and found “equal or higher protection from natural infection, both for symptomatic and asymptomatic infection”. But under this scheme, our care worker would still be exposed to the additional risks of vaccination. Moreover, if she has to take time off sick with the common side-effects, thanks to her zero-hours contract, she won’t be eligible for sick pay for four days – and perhaps not then. </p>
<p>This won’t be the case for everyone. But it should be up to the individual who will suffer the outcome to make an informed choice. That is perhaps the most basic tenet of medical ethics: respect for autonomy. </p>
<p>It is true that autonomy is not always decisive in public health and that care workers have professional responsibilities to those in their care. But to justifiably override autonomy and remove someone’s livelihood, we need to know that doing so will be an effective measure and that it is necessary. </p>
<p>Increasing vaccine uptake may only have a limited effect in preventing transmission. The <a href="https://www.gov.uk/government/news/one-dose-of-covid-19-vaccine-can-cut-household-transmission-by-up-to-half">very limited data</a> available suggests only a limited effect (as low as 35% and up to 50%). There are also <a href="https://www.cbc.ca/news/canada/calgary/foothills-delta-variant-outbreak-calgary-covid-1.6063802">confirmed reports</a> of breakthrough infections, and even outbreaks, among fully vaccinated staff and patients.</p>
<p>Vaccination will confer some protection. But, at best, mandatory vaccination won’t stop family and friends from transmitting the virus while visiting care homes. Singling out one group for the coercive measure will be divisive and <a href="https://www.carehome.co.uk/news/article.cfm/id/1647914/Fears-grow-mandatory-staff-vaccination-could-make-care-home-workers-unemployable">may lead many staff to leave the already-understaffed profession</a>. </p>
<p>The policy is also unnecessary. Half of care homes have hit the target level of staff vaccination through voluntary means. Staff could be offered incentives to be vaccinated. </p>
<p>We should ensure the risks the vulnerable face are reasonable. But this isn’t a vaccine with the safety track record of the flu or hepatitis vaccine. I think the COVID vaccines are in most people’s best interests. But that’s a decision people should make for themselves.</p><img src="https://counter.theconversation.com/content/162876/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dominic Wilkinson receives funding from the Wellcome Trust (203132/Z/16/Z) and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation Pandemic Ethics accelerator <a href="https://ukpandemicethics.org">https://ukpandemicethics.org</a> (AH/V013947/1).</span></em></p><p class="fine-print"><em><span>Julian Savulescu receives funding from the Wellcome Trust (203132/Z/16/Z) and the Arts and Humanities Research Council (AHRC) as part of the UK Research and Innovation Pandemic Ethics accelerator <a href="https://ukpandemicethics.org">https://ukpandemicethics.org</a> (AH/V013947/1). He is a Partner Investigator on an Australian Research Council Linkage award (LP190100841) which involves industry partnership from Illumina. He does not personally receive any funds from Illumina.</span></em></p>The UK government is set to make it compulsory for all staff working in care homes in England to get the COVID vaccine. Two ethicists discuss the pros and cons.Dominic Wilkinson, Consultant Neonatologist and Professor of Ethics, University of OxfordJulian Savulescu, Visiting Professor in Biomedical Ethics, Murdoch Children's Research Institute; Distinguished Visiting Professor in Law, University of Melbourne; Uehiro Chair in Practical Ethics, University of OxfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1624662021-06-11T15:50:20Z2021-06-11T15:50:20ZHow COVID-19 exposed the systemic ageism at the heart of Britain<figure><img src="https://images.theconversation.com/files/405912/original/file-20210611-25-1024l1r.jpg?ixlib=rb-1.1.0&rect=59%2C23%2C7856%2C5154&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Media coverage of elderly deaths throughout the pandemic revealed the deep-seated ageism that exists in the UK.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-healthy-man-walks-by-elderly-1853550058">Alrandir/Shutterstock</a></span></figcaption></figure><p>The UK public cares deeply about injustices. In the first few months of 2021, thousands of people took to the streets demanding much-needed social changes, from <a href="https://www.theguardian.com/world/2021/may/22/anti-racism-protesters-gather-in-london">Black Lives Matter</a> to <a href="https://www.bigissue.com/latest/what-are-the-kill-the-bill-protests-police-crime-sentencing-courts-bill/">Kill the Bill</a> protests against the government’s proposed new crime legislation, the <a href="https://www.independent.co.uk/news/uk/home-news/sarah-everard-met-police-vigil-protest-latest-b1817072.html">vigil for Sarah Everard</a> and massive demonstrations against <a href="https://news.sky.com/story/thousands-march-in-london-to-demonstrate-against-gaza-violence-12306994">Israel’s bombing of Gaza</a>. Why then, haven’t the deaths of 138,163 people from coronavirus resulted in the same kind of outpouring of public anger? </p>
<p>A look at the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/articles/coronaviruscovid19roundup/2020-03-26#health">data</a> provides a significant clue: 88% of COVID deaths have been people aged 65 and over. To understand why older people have died en masse, and why there has been no sustained public outcry, requires close examination of the deep-seated ageism that permeates British society. </p>
<p>As a researcher studying the representation of older people in mainstream media, I have found that ageism has been commonplace in the UK for decades – from the increasingly unrealistic <a href="https://www.sciencedirect.com/science/article/abs/pii/S0890406518302706">cultural portayals</a> of older people as evergreen, endlessly resilient and non-dependent, to high rates of <a href="https://www.jrf.org.uk/data/pensioner-poverty">pension poverty</a> (especially among women) and the <a href="https://www.nytimes.com/2019/02/24/world/europe/britain-austerity-may-budget.html">dismantling</a> of a welfare system designed to care for the elderly. But during the coronavirus pandemic this creeping ageism became pronounced. </p>
<p>This is clear from the way the media have portrayed older people over the last 15 months. When the pandemic erupted, articles published in the British <a href="https://www.telegraph.co.uk/global-health/science-and-disease/coronavirus-qahow-help-older-people/">right-</a> and <a href="https://www.theguardian.com/world/2020/mar/08/grandparents-fears-of-virus-risk-emergency-childcare">left-wing</a> media reiterated that older people were at increased risk of dying from the virus. In this way, the public came to anticipate older people’s deaths and consider them a natural outcome of the disease. </p>
<p>The elderly, on average, are more susceptible to the virus, but it was stressed time and time again in order to alleviate public fears. As <a href="https://www.telegraph.co.uk/health-fitness/body/coronavirus-covid-19-advice-stockpile-self-isolate-work-children-twice/">one newspaper report</a> put it: “Providing you aren’t elderly or suffering from an existing illness, you needn’t panic.” </p>
<p>At the same time older people were being portrayed as vulnerable and cast as more likely to die, they also disappeared from the news cycle. </p>
<p>In fact, well before older people began to die from COVID-19, their lives were considered already lost by some. On 12 March 2020, before the first lockdown, Boris Johnson told families that many were going to lose loved ones. It was clear who the prime minister was referring to when he spoke of these loved ones. Shockingly, even as he seemed to intimate that the lives of the elderly were not worth safeguarding, Johnson was subsequently commended by many for being <a href="https://www.dailymail.co.uk/news/article-8105763/Boris-Johnson-steps-coronavirus-response-Cobra-crisis-meeting.html">“frank”</a>. </p>
<p>The depiction of older people as extremely vulnerable, coupled with their existing invisibility prepared the ground for things to come. Their deaths were rendered acceptable. </p>
<figure class="align-center ">
<img alt="Black and white image of old lady in distress covering her face with her hand." src="https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=402&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=402&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=402&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=505&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=505&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405920/original/file-20210611-23-b2nq4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=505&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Though the media covered the plight of the elderly throughout the pandemic, rarely were their own voices heard.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-age-lifestyle-concept-black-white-1266091135">Drop of Light/Shutterstock</a></span>
</figcaption>
</figure>
<h2>Negligence and carelessness</h2>
<p>As mortality rates among the elderly <a href="https://www.bbc.co.uk/news/health-52284281">rose to the thousands</a> in April-May 2020, particularly within care homes, media outlets began to count the dead. Yet older people occupied headlines only as abstract statistics, while their names, voices, faces and testimonies rarely appeared. </p>
<p>While the elderly themselves remained anonymous, their predicament was represented through gloomy stock images or mentioned in passing as they were described lying on their deathbed without anyone holding their hand. The portrayal of their helplessness framed these deaths as tragic but also inevitable. The focus fixed on family relatives who told of their traumas, alongside the accounts of care home providers. The voices of the elderly were simply not heard. </p>
<p>Slowly, the arguably <a href="https://www.opendemocracy.net/en/can-europe-make-it/acceleration-death-precipitated-covid-19-exposes-state-crime/">criminal negligence</a> and carelessness with which Johnson’s administration dealt with the elderly, was exposed. <a href="https://news.sky.com/story/coronavirus-discharged-hospital-patients-may-have-seeded-covid-19-into-care-homes-minister-admits-11991246">Evidence</a> began emerging about how care homes were instructed by the Department of Health and Social Care to admit patients discharged from hospitals without undergoing a COVID-19 test, while elderly “do not resuscitate” patients also <a href="https://www.mirror.co.uk/news/uk-news/elderly-people-being-pressured-signing-21826505">made the headlines</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-coronavirus-reveals-the-way-we-regard-ageing-and-old-people-135134">How coronavirus reveals the way we regard ageing and old people</a>
</strong>
</em>
</p>
<hr>
<p>This set the stage for media coverage on the dire state of elderly care in the UK. <a href="https://www.mirror.co.uk/news/uk-news/care-homes-could-collapse-within-22002465">Some stressed</a> the fact that 84% of care homes are poorly run by mainly for-profit private providers. </p>
<p>Encouragingly, for a few weeks the media debated key issues regarding elderly care. Those included the <a href="https://www.theguardian.com/world/2020/may/18/agency-staff-were-spreading-covid-19-between-care-homes-phe-found-in-april">high turnover of care workers</a> (primarily due to inadequate working conditions), the <a href="https://www.theguardian.com/society/2020/may/14/care-home-residents-families-demand-restart-of-inspections">lack of proper regulation</a> of care homes, and the high rates of older people <a href="https://www.theguardian.com/society/2020/may/13/charities-report-rise-in-older-people-struggling-for-food-in-lockdown">living in poverty and isolation</a>. For a moment it seemed that change was possible. </p>
<p>But news comes and goes, and the government <a href="https://www.reuters.com/world/uk/uks-pm-johnson-announces-covid-19-public-inquiry-2021-05-12/">deflected the criticism</a>. Even though the media has exposed the extraordinary neglect leading to a huge number of deaths among over-65s in the UK, the structural ageism that enabled it has yet to be acknowledged. On the contrary, it continues to be reproduced in the media, where the elderly are still portrayed as faceless, voiceless and ultimately expendable. </p>
<p>The deafening silence over the unnecessary deaths of Britain’s elderly underscores that the illness endangering our society is not simply a virus, but a careless and systematic ageism. It will carry on spreading and killing the elderly so long as the silence persists.</p><img src="https://counter.theconversation.com/content/162466/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Shir Shimoni does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Even though the media exposed the negligence that led to so many elderly deaths, it continues to portray old people as faceless and voiceless, contributing to the insidious spread of ageism.Shir Shimoni, PhD candidate, Culture, Media and Creative Industries, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1584922021-04-12T13:59:18Z2021-04-12T13:59:18ZCare homes: why investment firms can be bad owners<figure><img src="https://images.theconversation.com/files/393979/original/file-20210408-21-pefjtf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The view from above. </span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/og_p3b9bJ7E">Nick Karvounis/Unsplash</a></span></figcaption></figure><p>The ailing social care system in England <a href="https://www.thetimes.co.uk/article/social-care-reform-to-be-announced-in-queens-speech-hints-boris-johnson-53c29qqvw">is due to be reformed</a> as part of plans being announced in the Queen’s Speech in May. The most prominent issue is long-term funding, with the UK prime minister, Boris Johnson, recently talking up the need for a “ten-year plan” to fix the sector. </p>
<p>But while reform is good news, the question of how to fund the sector is not the only one that needs to be asked. There are fundamental questions about who is providing (and profiting from) social care, and how this affects quality and economic stability in the sector. </p>
<h2>The care market</h2>
<p>Like <a href="https://journals.sagepub.com/doi/abs/10.1177/0958928712449772?casa_token=p5kfXTax_xAAAAAA%3AhEmcTxF_LbOYVSZV5T5Vh7fMenhPhMH4Wb4xi-EjOVzdbbb6-BKk86NTxDXc_cVyRaNqttRQV8dg6g&journalCode=espa">many European countries</a>, UK adult social care is a quasi market. It is provided by a mix of private, voluntary and public players. Private companies and financial investment groups got involved after the marketised structure
<a href="https://www.theguardian.com/social-care-network/2015/oct/13/social-services-care-reform-homecare">emerged in the 1990s</a>. </p>
<p>In 2019, private players <a href="https://www.ippr.org/files/2019-09/who-cares-financialisation-in-social-care-2-.pdf">provided 84%</a> of care home beds. Local authorities and the National Health Service <a href="https://chpi.org.uk/wp-content/uploads/2019/11/CHPI-PluggingTheLeaks-Nov19-FINAL.pdf">cover the cost</a> of about half of these services, on a means-tested basis, while the clients and their families pay the rest (see graphic below – click to make it bigger).</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphic explaining social care spending in UK" src="https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393638/original/file-20210406-21-1s3svdf.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.cusp.ac.uk/themes/aetw/wp26-careless-finance/">Careless Finance</a></span>
</figcaption>
</figure>
<p>The sector has many small providers. <a href="https://webcache.googleusercontent.com/search?q=cache:GPxHOvXm8-4J:https://researchbriefings.files.parliament.uk/documents/CBP-8003/CBP-8003.pdf+&cd=12&hl=en&ct=clnk&gl=uk">Barely one-third</a> of beds are in the hands of the top 25 companies, and the top five control about 11% of the market. Nonetheless, the five leading operators – HC-One, Four Seasons, Care UK, Barchester and Bupa – <a href="https://www.statista.com/statistics/1117404/leading-retirement-homes-operators-by-nursing-beds-united-kingdom/#:%7E:text=In%202019%2C%20HC%2DOne%20Ltd,17%2C000%20and%2012%2C400%20beds%20respectively">still provide</a> some 50,000 beds between them. </p>
<p>Of the five, HC-One and Care UK are currently owned by <a href="https://www.investopedia.com/terms/p/privateequity.asp#:%7E:text=Private%20equity%20is%20an%20alternative,the%20delisting%20of%20public%20equity">private equity firms</a>. Four Seasons also had a private equity owner (Terra Firma) until it went into administration in 2019, and <a href="https://www.ft.com/content/eab8c4c4-d49a-11e9-8367-807ebd53ab77">was acquired</a> by US-based hedge fund H/2 Capital. Barchester is majority-owned by three Irish billionaires, Dermot Desmond, John Magnier and JP McManus as part of a group of 50 investors. <a href="https://weownit.org.uk/company/bupa#:%7E:text=Bupa%20%7C%20We%20Own%20It,private%20company%20limited%20by%20guarantee.">Bupa is</a> a not-for-profit private company, meaning it reinvests all profits back into the business.</p>
<p><strong>Top five care companies</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="UK top five care companies" src="https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=222&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=222&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=222&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=279&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=279&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394302/original/file-20210409-23-1fyn9x4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=279&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.cqc.org.uk/get-involved/consultations/world-health-social-care-changing-so-are-we">CQC2021</a></span>
</figcaption>
</figure>
<p>There have been many concerns about financial investment outfits being involved in care provision, and whether this has negatively affected economic stability and the quality of care. As well as the Four Seasons failure, private equity was at the centre of the collapse of then leading UK provider <a href="https://www.theguardian.com/business/2011/jun/03/southern-cross-care-private-equity">Southern Cross</a> in 2011. </p>
<p>Investment firms have become notorious in many sectors for taking over underperforming companies and loading them with debt, before using short-term strategies to maximise their profits for a quick return. With private equity, there is the additional issue that they are not listed on the stock market and therefore less regulated than listed investors in relation to financial disclosure requirements.</p>
<p>But what does the data say about how these financial entities affect the care sector? Our new <a href="https://www.cusp.ac.uk/themes/aetw/wp26-careless-finance/">Careless Finance</a> report at international research network the Centre for the Understanding of Sustainable Prosperity aimed to find out. </p>
<h2>What we know</h2>
<p>The evidence that for-profit care homes deliver worse-quality care than voluntary and public sector operators is compelling. From Taiwan and Australia to <a href="https://www.sciencedirect.com/science/article/pii/S0277953617301351?casa_token=6QOmrTrwUMQAAAAA:dRt34RoqAxYxNuKnLnM9OEOtzsQAPERFhcs69UI961fkjt1xFyZq14EtSs3hTWEfRzvqAjIUfQ">the UK</a> and the US, many studies <a href="https://www.bmj.com/content/339/bmj.b2732.long">have found</a> that for-profit operators have on average fewer staff hours per resident and worse indicators for quality of service. </p>
<p>When it comes to the specific impact of investment companies, the results are more mixed. The evidence tends to focus on private equity ownership, is highly US-centric, and looks primarily at nursing homes <a href="https://caretobedifferent.co.uk/whats-the-difference-between-a-care-home-and-a-nursing-home/">as opposed to</a> residential care. Many studies do indicate that private equity <a href="https://www.nber.org/papers/w28474">can reduce</a> certain <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1475-6773.2011.01311.x?casa_token=BL-nLLM3U8UAAAAA%3AKnXJoC3GMW3-nIPF562czmMm_sK1SMMO_DAOUZ8HRXK29uL5f7RwH8t3kT38zA9Z-qu_xr0XuR9f1WCa">measures of</a> quality <a href="http://healthfinancejournal.com/index.php/johcf/article/view/12">of care</a>, but others <a href="https://link.springer.com/article/10.1007/s10754-018-9254-z">find</a> no impact at all. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Old woman in care home eating a yoghurt" src="https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=543&fit=crop&dpr=1 600w, https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=543&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=543&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=682&fit=crop&dpr=1 754w, https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=682&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/393977/original/file-20210408-21-1p1h7tq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=682&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The research evidence has its limitations.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/GhKB74M4d4c">Olga Bogdanova/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>How can this difference in findings be explained? Nursing home quality and governance experts Aline Bos and Charlene Harrington <a href="https://journals.sagepub.com/doi/full/10.1177/0046958017742761">hit the nail on the head</a> when they point out that private equity ownership <em>per se</em> is not the problem. Rather, it is the particular management strategies – such as reducing the number of registered nurses or time spent with clients – that can negatively affect quality. Some studies might therefore be looking at the wrong link in the chain.</p>
<p>Several management strategies and <a href="https://www.cusp.ac.uk/themes/aetw/wp26-careless-finance/">financial practices</a> associated with investment companies can affect quality of care and undermine care companies’ long-term financial stability. For example, recent US research <a href="https://www.sciencedirect.com/science/article/abs/pii/S1544612320301549?casa_token=UW0NK2Di8U4AAAAA:UI7RQmMRoDkawiNxXAaHPK8ED_Gif7UUJxel4Y7kmYKef-luWcvguzrjc1yXSv6UdRd-i-_WAw">indicates that</a> leveraged buyouts – where an investment firm buys a company using a large proportion of debt – “increase the probability of bankruptcy for the target firm by approximately 18%”.</p>
<p>For companies that provide foundational welfare services to some of the most vulnerable in society, this is a worrying prospect. </p>
<p><a href="https://www.cusp.ac.uk/themes/aetw/wp26-careless-finance/">All five</a> of the UK’s largest care home chains exhibit signs of financial engineering. Three have seen leveraged buyouts, while four have complex group structures, including related companies in tax havens, intra-group loans and <a href="https://www.wpcarey.com/sites/default/files/2020-11/WPC_NREI-Outlook_Midyear-2019_20190801.pdf">sale and leaseback arrangements</a> (where a care home property is sold off and rented back to the social care company).</p>
<p><strong>Top five operators and financial arrangements</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Table showing which top five operators have been subject to financial engineering" src="https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=167&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=167&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=167&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=210&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=210&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394309/original/file-20210409-17-takxk5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=210&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">One star: The data in this table comes from the 2018/19 accounts for each company.
Two stars: The company structure of Care UK has changed since these accounts were published. According to a spokesperson, the assets of Silver Sea Holdings (a company registered offshore) have been transferred to a UK-based legal entity, owned by Care UK Property Holdings Limited. We are therefore now unclear about the current use of these structures by the company.
Three stars: Four Seasons Health Care went into administration in 2019, so the data may not reflect its current financial structure.</span>
<span class="attribution"><a class="source" href="https://www.cusp.ac.uk/wp-content/uploads/Careless-finance-final.pdf">Careless Finance</a></span>
</figcaption>
</figure>
<p>Three out of five of these operators have more care homes than average in either the “requires improvement” or “inadequate” quality ratings categories, as shown below (though one of them, Bupa, also has a disproportionate number of “outstanding” homes) . This is based on the most recent inspections by the Care Quality Commission regulator, which were conducted in the past year for all homes in the bottom two categories.</p>
<p>The below-average performances by some of these operators could be for many reasons. The companies might be buying lower-quality care homes to begin with because they see a greater opportunity for value growth. Equally, the average number of beds in these chains could well be higher – something <a href="https://www.jstor.org/stable/3768307?casa_token=sQwJ7SxYHjsAAAAA%3A5SnuwseQ041gjGvqHGNMT_MmzGgKxhIKGuLUI3AmV5YObp516RyVC93Ko-YjyEgDZoJ07CNRFi96Ugqg4CHPc7zVJo_sIGfb5KxeQZmQXsf81h0plajl&seq=1#metadata_info_tab_contents">known to be associated</a> with lower-quality care. </p>
<p><strong>Care homes in each quality category, by operator</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Graphs showing percentages of care homes in each of the Care Quality Commission's different ratings categories" src="https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=458&fit=crop&dpr=1 754w, https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=458&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/394261/original/file-20210409-19-22jb4v.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=458&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Data from April 1 2021.</span>
<span class="attribution"><span class="source">Care Quality Commission</span></span>
</figcaption>
</figure>
<p>Because of the complexity of the factors that determine quality outcomes, careful research is required to identify the role of each management strategy and financial practice. But given the relationships identified in the US, this certainly calls for a closer look in the UK.</p>
<p>The large proportion of public funding going to these companies makes this a clear issue of public accountability. With social-care reform apparently imminent, the government should surely get a better handle on the scope and depth of these challenges. Proposals to limit potentially damaging aspects of financialisation could then be brought forward, such as <a href="https://chpi.org.uk/papers/reports/plugging-the-leaks-in-the-uk-care-home-industry/">enhanced financial transparency</a>, restrictions <a href="https://www.soas.ac.uk/economics/research/workingpapers/file150390.pdf">on companies</a> that use tax havens, and limiting <a href="https://hummedia.manchester.ac.uk/institutes/cresc/research/WDTMG%20FINAL%20-01-3-2016.pdf">high-risk</a> financing techniques.</p>
<p>To make proposals focused solely on long-term funding – as vital as that may be – would be a missed opportunity. It would risk leaving social care on a path of continued economic instability and crisis.</p>
<hr>
<p>We invited the top five operators to respond to the findings in this article. A spokesperson for Barchester said:</p>
<blockquote>
<p>Barchester is not loaded with debt, as is clear from our annual reports filed at Companies House. Also, there is no short-term strategy to maximise profits for a quick return because Barchester has been under the same ownership for over 18 years. Although certain care home groups have had well-documented financial issues, this is simply not the case with Barchester.</p>
<p>Barchester does not operate with “fewer staff hours per resident, poor working conditions and worse quality indicators” and is not at risk of bankruptcy. We reinvest more than half our operating profits in upgrading facilities and this contributes significantly to the wellbeing of staff and residents alike. We are also proud to say we are an above national minimum wage and national living wage employer, unlike most other large providers.</p>
<p>On long-term financial viability, Barchester’s profits before tax have grown significantly over the last five years. Barchester’s regulatory approval has also improved significantly, from 69% of services rated “good” or “outstanding” in 2015 to 88.3% today. </p>
<p>Over the last five years, Barchester has paid £28 million in corporation tax. With the exception of two care homes in Jersey, all Barchester care homes contribute to profits in the UK and pay corporation tax on that basis.</p>
<p>Barchester has invested some £127 million in capital expenditure over the last five years. Its capital expenditure has increased, year-on-year, to the extent that such annual investment has more than doubled over this period of time.</p>
<p>By almost all metrics, Barchester has outperformed other care home providers, both in the private sector and not for profit establishments. This is notwithstanding the impact of the COVID-19 pandemic.</p>
<p>Barchester has also been awarded Best Company accreditation in each of the last two years (being the only one of the large healthcare providers to have received such accreditation), in recognition of the regard that staff have for the business as an employer. Furthermore, Barchester has in each of the last two years won the ROSPA Award for Health and Safety (again, the only healthcare provider, public or private, to have done so).</p>
</blockquote>
<p>A spokesperson for Care UK said:</p>
<blockquote>
<p>You mention that many investment firms take a short-term approach to their acquisitions. This has not been our experience. We have been partnered with Bridgepoint for over ten years now, and it is their commitment and long-term vision which has enabled us to bring a significant amount of much needed investment to the sector. Since 2014 we have invested more than £200 million in opening 49 new homes, creating much needed capacity, and this is above and beyond the circa £18 million a year we invest on upgrades to our existing care homes.</p>
<p>We have no inadequate homes and operate more outstanding-rated homes than any other provider. It is also worth noting that we have a much higher proportion of nursing homes in our portfolio than many other providers, and on these more challenging services, we are 5.9% ahead of sector averages on good and outstanding homes. </p>
<p>Nothing in our quality ratings, colleague engagement scores or customer satisfaction ratings would support any allegations of poor working conditions or quality indicators. </p>
</blockquote>
<p>A spokesperson for Bupa said: </p>
<blockquote>
<p>Bupa is a large, international healthcare organisation. For context, our UK aged care business represents 3% of Bupa’s global business in terms of revenue. We are not backed by private equity. We do not have shareholders and all our profits are invested back into healthcare. It is therefore misleading to draw comparisons between our structure and that of other UK-based care home operators.</p>
</blockquote>
<p>The remaining top-five operators declined to comment in time for publication.</p><img src="https://counter.theconversation.com/content/158492/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Corlet Walker receives funding from the Economic and Social Research Council. </span></em></p>The UK government is about to reform social care, but the focus is likely to be on funding, not the companies that are allowed to have a stake in the sector.Christine Corlet Walker, PhD Candidate in Ecological Economics, University of SurreyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1579212021-03-29T15:45:42Z2021-03-29T15:45:42ZCare homes: evidence emerging of inappropriate use of ‘do not attempt CPR’ orders during pandemic<figure><img src="https://images.theconversation.com/files/392226/original/file-20210329-25-1fjhw5n.jpg?ixlib=rb-1.1.0&rect=437%2C112%2C6871%2C3750&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock/YuganovKonstantin</span></span></figcaption></figure><p>Imagine that death is just around the corner. How will you spend your final moments? Quietly with loved ones? With a priest giving last rites? Perhaps listening to your favourite music? Or how about being subjected to 300-joule electric shocks while your ribs are broken, undergoing a medical procedure that is <a href="https://journals.sagepub.com/doi/full/10.1177/1751143719832162">unlikely to succeed</a>?</p>
<p>Cardio-pulmonary resuscitation (CPR) is an emergency procedure that can save lives – although less often than your favourite TV drama <a href="https://www.sciencedirect.com/science/article/abs/pii/S0300957215003731">might suggest</a>. It rightly forms a central part of standard first aid courses and clinical training. But as well as knowing how to use CPR, medics also need to know when <em>not</em> to use it – an issue more pertinent than ever as the pandemic has hit care homes with <a href="https://www.nuffieldtrust.org.uk/news-item/covid-19-and-the-deaths-of-care-home-residents?gclid=Cj0KCQjwjPaCBhDkARIsAISZN7R3v-jTRgrYD3JoRyca-f2zM_-wS-ZJrDZf5019_vNRKj8NU6PjCF0aAmHMEALw_wcB">tremendous force</a>.</p>
<p>Whether or not to perform CPR is no easy decision. Several factors have to be taken into account: How fit and healthy is the patient? What is the chance of success of CPR in this patient, right now? How likely are adverse clinical outcomes, such as brain damage? And does this patient even want CPR?</p>
<figure class="align-center ">
<img alt="Hand pressing down on the chest of a medical dummy." src="https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/392236/original/file-20210329-19-1txse0w.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People doing CPR training on a medical dummy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cpr-training-medical-proceduredemonstrating-chest-compressions-649412104">Shutterstock/BlackDuckStyle</a></span>
</figcaption>
</figure>
<p>This decision is often – and ideally – made before an emergency arises. A Do Not Attempt CPR (DNACPR) order is used to let medical professionals know they should not attempt the procedure. This should be an individualised decision, made and recorded in consultation with the person in question. </p>
<p>It should reflect not only their specific medical situation, but also their personal beliefs, values and wishes. For example, someone may prefer to accept death rather than resort to heroic medical measures. This information then informs a “now or never” decision about whether to resort to CPR or not.</p>
<p>But as with so many things at present, COVID has potentially created a problem here. A new report from the <a href="https://www.cqc.org.uk/sites/default/files/20210318_dnacpr_printer-version.pdf">Care Quality Commission</a> (CQC) has revealed that the pandemic may have increased improper use of DNACPR orders in care homes.</p>
<h2>Upsurge during pandemic</h2>
<p>The report shows that DNACPR orders have become more common during the pandemic: the percentage of nursing home residents with an order in place rose from 74% to 92% from March to December 2020. </p>
<p>According to the report, 71% of people with a DNACPR decision in place told the CQC they felt completely or mostly supported to participate in a conversation about this decision and 70% said they felt completely or mostly listened to and able to speak up. While that is not a perfect record, it shows that patients can and do feel empowered by conversations surrounding these orders. </p>
<p>But the report also raises significant concerns. Almost half the respondents to the public survey felt they had been discriminated against or treated unfairly during the DNACPR process. Some 6% of adult social care providers told the CQC that “<a href="https://www.theguardian.com/society/2021/mar/18/blanket-do-not-resuscitate-orders-imposed-on-english-care-homes-finds-cqc">blanket</a>” DNACPR decisions had been made – meaning they were applied across the board rather than on the basis of individual assessment and consultation. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1372479185286012928"}"></div></p>
<p>These figures may point to poor practice and serious violations of anti-discrimination and human rights laws (for example the <a href="https://www.equalityhumanrights.com/en/human-rights-act/article-2-right-life#:%7E:text=1.,penalty%20is%20provided%20by%20law.">right to life</a>).</p>
<p>The CQC report provides some much needed insight into the use of DNACPR orders during the pandemic. But it also leaves a number of important questions unanswered. Why did DNACPR orders became more common? Why were “blanket” decisions made, and how? </p>
<p>The report focuses mainly on how DNACPR orders are adopted and pays little attention to how they are being interpreted and used. Yet scrutiny about their interpretation and use is also important. </p>
<p>As the name suggests, a DNACPR order refers to cardio-pulmonary resuscitation only: it is a narrowly defined medical instruction. It does not apply to other forms of resuscitation – rehydration, for example, or the treatment of shock. Much less does it apply to other forms of care. That’s why it’s dangerous to use shorthands like DNR (Do Not Resuscitate) or DNAR (Do Not Attempt Resuscitation), which wrongly suggest a broader application. </p>
<p>But are DNACPR orders being used within these boundaries? Or are there forms of mission creep whereby a DNACPR order is used to limit care more broadly? The CQC report mentions anecdotal evidence that one person with a DNACPR order in place was denied treatment altogether, but does not provide further information about the issue.</p>
<p><a href="https://autonomy.essex.ac.uk/covid-19/human-rights-in-care-homes/">Our new study</a> may shed light on some of these unanswered questions, picking up where the CQC report left off. The research we are doing at the <a href="https://www.essex.ac.uk/research-projects/essex-autonomy-project">Essex Autonomy Project</a>, focuses on human rights in locked down care homes. Initial findings from an ongoing <a href="https://essex.eu.qualtrics.com/jfe/form/SV_3kNq1xtDDuHNFnE">online survey</a> suggest that 19% of care professionals working in or with care homes during the pandemic witnessed DNACPRs influencing medical decisions beyond CPR. </p>
<p>It’s imperative that we understand how COVID-19 has affected the use of DNACPR orders – to ensure everyone gets a say in decisions about their own life and death, but also to help care staff deal with these difficult decisions under the heightened pressures of the pandemic.</p><img src="https://counter.theconversation.com/content/157921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This article was written with the assistance of Vivek Bhatt, with research support provided by Emily Fitton. Financial support was provided by the Arts and Humanities Research Council; Grant Number AH/V012770/1: Ensuring Respect for Human Rights in Locked-Down Care Homes. </span></em></p><p class="fine-print"><em><span>Wayne Martin's research is supported by the Arts and Humanities Research Council and the Wellcome Trust.</span></em></p>Have ‘Do Not Attempt CPR’ orders been misused under the pressures of the pandemic?Margot Kuylen, Senior Researcher for the Human Rights in Care Homes project, University of EssexWayne Martin, Director, Essex Autonomy Project, University of EssexLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1562642021-03-12T14:46:55Z2021-03-12T14:46:55ZAfter COVID: why we need a change in care home culture<figure><img src="https://images.theconversation.com/files/389281/original/file-20210312-16-1nc1lcd.jpg?ixlib=rb-1.1.0&rect=27%2C9%2C6011%2C4010&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many care workers feel society does not value them or the people they look after. </span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-woman-her-caregiver-home-146517530">Alexander Raths/Shutterstock</a></span></figcaption></figure><p>For years, observers have spoken of a “social care crisis” in Scotland. Coronavirus has exposed existing weaknesses in the sector and created new problems. We know the dreadful impact <a href="https://www.bbc.co.uk/news/uk-scotland-55753816">COVID-19 had on care homes</a> highlighting this need for fundamental change.</p>
<p>In Scotland, out of a total of nearly 10,000 coronavirus deaths, more than <a href="https://www.gov.scot/publications/coronavirus-covid-19-daily-data-for-scotland/">34%</a> occurred in care homes. This has rightly been seen as a <a href="https://www.ft.com/content/d60cbffc-5b65-459a-92b6-895468c9c8a5">scandal</a>. A new culture of care is needed to underpin the sector, not piecemeal reform. Now, as we begin to contemplate a world after COVID-19, is the moment for such reform. And initial debates and ideas look promising.</p>
<p>Less often discussed is how care workers have been affected by the virus and what it has meant for their working conditions and overall job quality. <a href="https://www.gov.scot/publications/coronavirus-covid-19-daily-data-for-scotland/">Scottish government statistics</a> show that 26 care workers have died with the virus since the start of the pandemic, though it is not clear whether they contracted it at work.</p>
<p>At the same time, while NHS workers have been celebrated as heroes, care workers remained an afterthought. These overlooked workers were not surprised. Participants in our <a href="https://dwsc-research.org/">research project</a> on working conditions in care homes told us they have for long felt that society cares little about the elderly, and, by extension, cares little about those who work with them. As one told us:</p>
<blockquote>
<p>I don’t think society values care workers or the people we look after – they don’t treat them or us with the respect and support we deserve.</p>
</blockquote>
<h2>Fair and decent work</h2>
<p>Our project explored what care workers in Scotland think about their job quality and what needs changing. Chiefly, participants claimed the important factors that “make work decent” are in short supply.</p>
<p>Care workers want more supportive managers who themselves are supported better; decent pay which takes into account the real skills that care work requires and is based on systematic job evaluations; decent terms and conditions including sick pay beyond the statutory minimum; and job security with a curb on casual employment.</p>
<figure class="align-center ">
<img alt="A couple outside their house clapping for the NHS during COVID." src="https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/389283/original/file-20210312-23-1la1yzi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Did the nation overlook the contribution of care workers in favour of the NHS during COVID?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/uckfield-sussex-united-kingdom-april-30-1718817454">Sarah Bardsley/Shutterstock</a></span>
</figcaption>
</figure>
<p>Of course, a safer work environment was listed as important too. Many said they felt their mental and physical health mattered little in their workplaces even before COVID-19, which made the issue only more severe. One factor crucial to making work feel decent and worthwhile is purpose and meaning. Many care workers say they remain in the job because their work has an abundance of both: </p>
<blockquote>
<p>It keeps you going when other aspects of the work aren’t so good. Just knowing that you’re enriching someone’s life is a reward.</p>
</blockquote>
<p>The lack of social recognition is key to understanding why, overall, their job
quality is low. Many interviewees were angry about care work being seen as merely “wiping bums” and requiring few skills. The lack of recognition should be understood in context of the high regard in which the NHS is held.</p>
<p>Despite the many years of <a href="https://www.legislation.gov.uk/asp/2014/9/contents/enacted">health and social care integration</a> at policy and strategy levels, Scottish care workers see their sector pitted against the NHS. Those working in the care sector, even care home managers, are made to feel like failures: “Why don’t you work in the NHS?”, is a question they hear too often. It is little wonder that the clap for NHS workers, during the height of the first wave of the pandemic, was perceived badly by most participants: </p>
<blockquote>
<p>Social care is very hard and difficult; people forget about us and only focus on doctors and nurses. It was all about ‘save our NHS '– how about us? </p>
</blockquote>
<p>Few of these findings came as a surprise as job quality problems have been noted before, by the Scottish <a href="https://www.fairworkconvention.scot/our-report-on-fair-work-in-social-care/">Fair Work Convention</a> in 2019 for example. What is striking is that so little has been done about them since. However, when interviewing representatives from local government, health and social care partnerships or industry umbrella organisations, we found that none were willing to take the lead in making decent work a priority. Responsibility for job quality always lies somewhere else. </p>
<h2>Do we need a national care service?</h2>
<p>Like every crisis, COVID-19 creates opportunities for change. For care workers, decent work should be on the cards now. The argument for improving job quality can be made by pointing out that consistently high-quality care – which is what everyone says they want for the most vulnerable in society – requires at least decent job quality.</p>
<p>The Scottish government’s <a href="https://www.gov.scot/binaries/content/documents/govscot/publications/independent-report/2021/02/independent-review-adult-social-care-scotland/documents/independent-review-adult-care-scotland/independent-review-adult-care-scotland/govscot%3Adocument/independent-review-adult-care-scotland.pdf">Feeley Review</a> of adult social care, set into motion in September 2020, is one of the most important initiatives regarding reform. Recommending a national care service for Scotland, the review appears to have the workforce at the heart of its thinking about a whole change in the culture of adult social care.</p>
<figure class="align-center ">
<img alt="The fence of a care home with a banner saying 'Heroes Work Here' against a rainbow." src="https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=368&fit=crop&dpr=1 600w, https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=368&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=368&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=463&fit=crop&dpr=1 754w, https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=463&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/389282/original/file-20210312-19-rdisjp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=463&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In Scotland, 26 care home workers died of COVID-19.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sign-outside-residential-care-home-elderly-1763719250">Peter Fleming/Shutterstock</a></span>
</figcaption>
</figure>
<p>It recommends minimum standards around what it calls “fair work” when it comes to local authorities buying in services from care providers and coordinated workforce planning. There is an encouraging endorsement of a job evaluation exercise around care jobs – this might help to create pay parity between social care and health care.</p>
<p>However, such changes would not address other job quality issues, which all connect to each other. One central problem is not sufficiently dealt with: why it is that social care workers are undervalued and experience low social esteem? Here, uncomfortable cultural questions need to be raised, with generational divides and ageism creating a demand for a new culture of care that recognises those needing care and those providing it.</p>
<p>Such a culture can be the foundation for efforts that create high-quality social care with a workforce that enjoys decent work, recognised skills and proper respect.</p><img src="https://counter.theconversation.com/content/156264/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Hartwig Pautz received funding for this research project from the British Academy's COVID-19 small research grant. </span></em></p><p class="fine-print"><em><span>Stephen Gibb received funding for this research project from the British Academy's COVID-19 small research grant.
</span></em></p>After the devastating impact of COVID, changing the culture of social care must start with valuing, respecting and rewarding the people who look after our vulnerable old people.Hartwig Pautz, Senior Lecturer in Social Sciences, University of the West of ScotlandStephen Gibb, Reader, School of Business and Creative Industries, University of the West of ScotlandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1461222020-09-14T14:37:48Z2020-09-14T14:37:48ZCoronavirus: dangerous to suggest that we should bin the rule of six<figure><img src="https://images.theconversation.com/files/357885/original/file-20200914-16-1ujmwa9.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5578%2C3579&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-friendly-african-girl-caucasian-keeping-1761315839">MandriaPix/Shutterstock</a></span></figcaption></figure><p>To combat the sharp rise in coronavirus infections, the UK government and the devolved administrations have imposed the “rule of six”. The rule stipulates that <a href="https://www.gov.uk/government/news/coronavirus-covid-19-what-has-changed-9-september">no more than six people</a> can meet socially – although a few exemptions apply. </p>
<p>The day before the rule came into force, Carl Heneghan, a professor of evidence-based medicine, and Tom Jefferson, a research fellow, both from the Centre for Evidence-Based Medicine at Oxford University, wrote an <a href="https://www.spectator.co.uk/article/boris-johnson-needs-to-bin-the-rule-of-six">opinion piece</a> for the Spectator, calling for the rule to be “binned”. The <a href="https://www.telegraph.co.uk/news/2020/09/13/bin-catastrophic-rule-six-say-scientists-risk-tipping-british/">Daily Telegraph</a> repeated Heneghan and Jefferson’s assertion that “life should return to as close as possible to normality”.</p>
<p>The number of COVID-19 cases has been rising rapidly in the last week. Unlike earlier in the summer when there were local outbreaks, the upsurge is now much more widespread. But hospital admissions and deaths are still relatively low, which prompted Heneghan and Jefferson to argue against tightening control measures. They might turn out to be right, but there are several reasons for not following the path they recommend. </p>
<h2>Three good reasons</h2>
<p>First, for much of the summer, most cases were in young people, who are at low risk of serious complications after infection. But there is now evidence that the rates of infection among older age groups are going up. </p>
<p>One thing we have learned in this pandemic is that even places held up as successful examples of pandemic control, such as Germany and Hong Kong, have not managed to shield the vulnerable when community transmissions rise above certain levels. Indeed, the UK Department of Health <a href="https://www.gov.uk/government/publications/covid-19-infection-rises-letter-to-care-providers-from-director-of-adult-social-care-delivery/covid-19-infection-rises-letter-to-care-providers-from-director-of-adult-social-care-delivery">wrote to care homes</a> on September 11 2020, warning them of signs of a rise in cases among care home staff. </p>
<p>Second, in the city of Leicester in the English midlands, where there was an outbreak in the summer, the increase of cases was reflected in hospital admissions and deaths. In July, there were <a href="https://www.leicester.gov.uk/your-council/coronavirus/coronavirus-in-leicester-latest-news/coronavirus-data-for-leicester/">24 deaths in Leicester</a>, more than any other local authority areas in the UK. </p>
<p>The city has a population of around 330,000 or about 1/200 that of the UK. If we crudely extrapolate its death rate in July to the entire UK, there would be 4,800 deaths in a month, or 160 daily. And this estimate is conditional on the epidemic curve not rising further since Leicester entered into a local lockdown. Is this a level that the society should accept as part of the “new normal”? </p>
<p>Spain and France have also seen a large upsurge of cases in recent weeks. That the number of deaths in these two countries is “limited” to several dozens a day properly emboldens commentators such as Heneghan and Jefferson, but they have forgotten that control measures have also been introduced there. They have probably forgotten also what happened in the spring in the UK. </p>
<p>Using Birmingham as an example, the level of community transmission now might be similar to the first week of March given the lack of testing then. A delay in introducing national lockdown then probably caused hundreds of extra deaths in Birmingham. </p>
<p>The chief executive of the local NHS Trust, which had the largest number of COVID-19 deaths in the UK during the first wave, <a href="https://www.birminghammail.co.uk/news/midlands-news/covid-red-alert-birmingham-hospitals-18912398">said last week</a> that there had been obvious surges in intensive-care admissions in the last two weeks. As a Birmingham resident whose office is 200m from the intensive care unit of this hospital, I can perhaps be forgiven for being less sanguine than Heneghan and Jefferson seem to be. </p>
<figure class="align-center ">
<img alt="Graph showing reported cases of coronavirus in Birmingham, with recent upwards curve." src="https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357887/original/file-20200914-14-65jnqk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="http://iancampbell.co.uk/">iancampbell.co.uk</a></span>
</figcaption>
</figure>
<p>Third, COVID-19 doesn’t just cause death. A substantial number of patients also suffer from what is now known as “<a href="https://www.bmj.com/content/370/bmj.m2815">long COVID</a>”. It is irresponsible to discount the risk of exposing millions of people to the infection when so little is known about the long-term prognosis.</p>
<h2>Simple instructions</h2>
<p>Johnson’s rule of six may prove to be over-cautious, as Heneghan and Jefferson suggest. Interestingly, they included Chris Whitty, England’s chief medical officer, in the group of “little more than a Dad’s Army of highly paid individuals” who came up with the idea. However, several senior members of Sage (the government’s scientific advisory committee) <a href="https://www.independent.co.uk/news/uk/politics/coronavirus-uk-covid-spread-cases-deaths-mark-walport-latest-b429942.html">have now issued</a> stern warnings. Meanwhile, <a href="https://abc30.com/coronavirus-pandemic-covid-19-dr-anthony-fauci-world-health-organization/6419117/">Anthony Fauci</a>, the eminent US physician, cautioned against looking at the rosy side of things in a pandemic. </p>
<p>The rule of six is an attempt to halt the virus and to simplify instructions. One of its important objectives is for schools to remain open and for university students to return to campuses. That is, for life to return to some normality. It would also still allow catering venues to operate. If those senior scientists are wrong, I would be as ecstatic as anyone to see the rule binned in due course. But if we listen to Heneghan and Jefferson now, the damage may be irreversible.</p><img src="https://counter.theconversation.com/content/146122/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>KK Cheng does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As the rule of six comes into force, some sectors of the media are already calling for it to be abolished.KK Cheng, Professor of Public Health and Primary Care Director of the Institute of Applied Health Research, University of BirminghamLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1458792020-09-14T11:23:45Z2020-09-14T11:23:45ZRobots to be introduced in UK care homes to allay loneliness – that’s inhuman<p>Some UK care homes are to <a href="https://www.theguardian.com/society/2020/sep/07/robots-used-uk-care-homes-help-reduce-loneliness">deploy robots</a> in an attempt to allay loneliness and boost mental health. The wheeled machines will “initiate rudimentary conversations, play residents’ favourite music, teach them languages, and offer practical help, including medicine reminders”. They are being introduced after <a href="https://www.carehomeprofessional.com/robot-care-home-trial-claims-significant-mental-health-benefits/">an international trial</a> found they reduced anxiety and loneliness.</p>
<p>These robots can hold basic conversations and be programmed to people’s interests. This is positive, but they are not a viable alternative to human interaction. It’s a sad state of affairs when robots are presented as solutions to human loneliness. Though intended as a way to fill in for carers in a “stretched social care system” rather than as a long-term solution, the use of robots is a slippery slope in removing the aged and infirm still further from the nerves and fibres of human interaction. </p>
<p>Robot companions have been trialled in the UK and Japan, from dogs that sit to attention to young women greeting isolated businessmen after a long day at work. They certainly serve a function in reminding people what it is to have companionship, helping with crude social interaction and providing cues to what it is to be human.</p>
<p>But robots cannot provide the <a href="https://www.independent.co.uk/life-style/gadgets-and-tech/features/robot-carer-elderly-people-loneliness-ageing-population-care-homes-a8659801.html">altruism and compassion</a> that should be at the core of a caring system. And they might even increase loneliness in the long term by reducing the actual contact people have <a href="https://link.springer.com/article/10.1007%252Fs10676-010-9234-6">with humans</a>, and by increasing a sense of disconnect. </p>
<p>While there have been <a href="https://www.sciencedirect.com/science/article/abs/pii/S1525861007005166">studies</a> showing robotic pets can reduce loneliness, such research is generally based on a contrast with no interaction at all, rather than a comparison of human and robotic interaction. </p>
<p>It’s also important to factor in the role of novelty, which is often missing in care home environments. In 2007, a Japanese nursing home <a href="https://www.reuters.com/article/us-japan-ageing-gadgets/robots-turn-off-senior-citizens-in-aging-japan-idUST29547120070920">introduced Ifbot</a>, a resident robot that provided emotional companionship, sang songs and gave trivia quizzes to elderly residents. The director of the faculty reported that residents were interested for about a month before they lost interest, preferring “stuffed animals” to the “communication robot”.</p>
<h2>Tactile connection</h2>
<p>The preference for stuffed animals is, I think, important, because it also connects to the sensory experience of loneliness. Cuddly toys can be hugged and even temporarily moulded by the shape and temperature of the human body. Robots cannot. There is a limit to the sense of connection and embodied comfort that can come from robotic caregivers, or pets. </p>
<p>This is not only because robots show insufficient cultural awareness, and that their gestures might sometimes seem a little, well, mechanical. It’s because robots do not have flesh and blood, or even the malleability of a stuffed toy. </p>
<p>Consider the <a href="https://link.springer.com/chapter/10.1007/978-1-4614-3967-7_2">controversial experiments</a> conducted by Harry Harlow in the 1950s that showed rhesus monkeys always preferred physical comfort to a mechanical caregiver, even if the latter had milk. Similarly, robots lack the warmth of a human or animal companion. They don’t respond intuitively to the movement of their companions, or regulate the heartbeats of their owners through the simple power of touch.</p>
<p>Loneliness is a <a href="https://www.theguardian.com/commentisfree/2018/nov/01/loneliness-illness-body-mind-epidemic">physical affliction</a> as well as a mental one. Companionship can improve health and increase wellbeing, but only when it is the right kind. </p>
<p><a href="https://www.helpguide.org/articles/mental-health/mood-boosting-power-of-dogs.htm">Stroking a dog</a> can be soothing for the person as well as the animal. Walking a dog also gets people out of the house where that is possible, and encourages social interaction.</p>
<p>As the owner of a young labrador, I am not always a fan of early rising. But I can see the positive emotional impact a pet has had on my young son, in contrast to many hours of technological absorption. An Xbox can’t curl up on your bed in the middle of the night to keep you warm. </p>
<p>And the infamous Labrador stink is like perfume to my son, who claims it makes him feel less lonely. So it’s smell, as well as touch, that is involved loneliness – along with <a href="https://www.ted.com/talks/fay_bound_alberti_a_historical_journey_through_loneliness">all the senses</a>.</p>
<figure class="align-center ">
<img alt="Aerial view of a cat and a dog on a person's lap." src="https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/357656/original/file-20200911-24-10ardnj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Robots can’t do this.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/hug-cat-dog-796895929">Chendongshan/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>Techno-fix</h2>
<p>I am not a technophobe. In the Zoom world of COVID-19, technological solutions have a critical role in making people feel included, seen and listened to. In time, it may be that some of the distancing effects of technology, including the glitchy movements, whirring sounds and stilted body language will improve and become more naturalised. Similarly, robot companions may well in time become more lifelike. Who will remember the early, clunky days of <a href="https://furreal.hasbro.com/en-gb">Furreal pets?</a> </p>
<p>But care robots are offering a solution that should not be needed. There is no reason for care home residents to be so devoid of human companionship (or animal support) that robot friends are the answer. </p>
<p>There is something dysfunctional about the infrastructure in which care is delivered, if robots are an economically motivated solution. Indeed, the introduction of robots into emotional care de-skills the complex work of caring, while <a href="https://www.newstatesman.com/science-tech/technology/2019/08/social-care-robots-privatise-loneliness-and-erode-pleasure-being">commercialising and privatising</a> responses to elderly loneliness.</p>
<p>It is often presented as “natural” or inevitable that elderly and infirm people live in homes, with other elderly and infirm people, shuttered away from the rest of the world. Care homes are an architectural way of concealing those that are least economically productive. There may be good homes, filled with happy residents, but there are many stories of people being ignored and neglected, especially <a href="https://theconversation.com/care-homes-have-long-been-neglected-the-pandemic-has-shown-us-how-bad-things-are-137458">during a pandemic</a>.</p>
<p>How we care for the elderly and the infirm is a cultural and political choice. Historically, elderly and infirm people were part of the social fabric and extended families. With a <a href="https://academic.oup.com/ageing/article/26/suppl_2/3/33629">globally ageing population</a>, many countries are revisiting how best to restructure care homes in ways that reflect demographic, economic and cultural needs. </p>
<p>Care home schemes in <a href="https://www.economist.com/europe/2019/08/08/a-dutch-care-home-experiments-with-housing-students-with-the-old">the Netherlands</a>, house students with elderly people and is popular with both. With a little imagination, care homes can be radically rethought.</p>
<p>New technologies have a role to play in society, just as they always have had in history. But they shouldn’t be used to paper over the gaps left by a withdrawal of social care and a breakdown in what “community” means in the 21st century. That’s inhuman.</p><img src="https://counter.theconversation.com/content/145879/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Fay Bound Alberti does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Using robots to provide companionship is a slippery slope in removing the aged and infirm still further from human interaction.Fay Bound Alberti, Reader in History and UKRI Future Leaders Fellow, University of YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1415492020-07-22T13:45:39Z2020-07-22T13:45:39ZCoronavirus: We need to support domiciliary care workers before the second wave hits<figure><img src="https://images.theconversation.com/files/346885/original/file-20200710-189224-am111w.jpg?ixlib=rb-1.1.0&rect=6%2C19%2C4383%2C2902&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/senior-handicapped-lady-wearing-face-mask-1677576226">FamVeld/Shutterstock</a></span></figcaption></figure><p>Many countries were already turning to domiciliary care <a href="https://www.kingsfund.org.uk/sites/default/files/media/commission-background-paper-social-care-health-system-other-countries.pdf">as an alternative</a> to residential care homes before the pandemic. The closure of care homes due to the well-publicised issues caused by COVID may hasten this change. </p>
<p>Domiciliary care allows people to stay in their own homes, which they often prefer. It may also be more <a href="https://www.euro.who.int/__data/assets/pdf_file/0008/181799/e96757.pdf">cost effective and sustainable</a> for a growing older population. </p>
<p>Domiciliary care providers support a wide range of people to live independent and fulfilling lives, including disabled adults, children and their families. But it is not without its risks during the pandemic. </p>
<p>People who use these services and their carers may be even more vulnerable during a second wave if care homes begin to close. The pandemic may also increase the demand for domiciliary care visits as more people are sent home after being <a href="https://www.gov.uk/government/publications/coronavirus-covid-19-providing-home-care/coronavirus-covid-19-provision-of-home-care">hospitalised with COVID</a>. </p>
<h2>The risk</h2>
<p>By the very nature of domiciliary care, carers move between homes with the potential to spread COVID among vulnerable people. A lack of resources, such as clear guidance, training, support and personal protective equipment, may prevent them from <a href="https://www.cqc.org.uk/news/stories/sharing-insight-asking-questions-encouraging-collaboration-cqc-publishes-first-insight-document-on-covid-19-pressures">providing good care</a> and put both themselves and those in their care at risk. Both will also be left <a href="https://www.theguardian.com/world/2020/jul/13/care-workers-left-unfairly-exposed-to-coronavirus">unfairly exposed</a> as they do not have the same access to regular testing as care home staff.</p>
<figure class="align-center ">
<img alt="COVID swab test" src="https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/348136/original/file-20200717-17-1ibbgj6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">People being cared for at home don’t have the same access to regular testing as care home staff.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/covid19-nasal-swab-laboratory-test-hospital-1670462338">Horth Rasur/Shutterstock</a></span>
</figcaption>
</figure>
<p>Deaths of people who receive domiciliary care in the UK are currently <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/deathsinvolvingcovid19inthecaresectorenglandandwales">triple those in previous years</a>. And for those with learning disabilities, deaths have more than <a href="https://www.cqc.org.uk/sites/default/files/20200615%20COVID%20IV%20Insight%20number%202%20final%20%281%29.pdf">doubled</a>. Yet this has not been widely reported, in part because of problems with the data, but also because domiciliary care is not an area of focus for those dealing with the pandemic. </p>
<p>Domiciliary care is often referred to as the “<a href="https://ukhcablog.com/blog/homecare-in-the-time-of-coronavirus/">poor relative</a>” of the care sector, with the UK government spending much less on it <a href="https://www.kingsfund.org.uk/sites/default/files/media/commission-background-paper-social-care-health-system-other-countries.pdf">than other countries</a>. Staff are often undervalued, paid meagre wages and have precarious contracts. </p>
<p>Increased <a href="https://www.adass.org.uk/media/7973/no-embargo-adass-budget-survey-report.pdf">financial instability in the care sector</a> as a result of the pandemic will have several undesirable effects, including placing <a href="https://www.cqc.org.uk/news/stories/sharing-insight-asking-questions-encouraging-collaboration-cqc-publishes-first-insight-document-on-covid-19-pressures">greater pressure</a> on family members and voluntary agencies to provide care. If care workers are unavailable or if people choose to cancel their care because of the risk of COVID, there could be longer term consequences. </p>
<p>Older people and those with disabilities may be left unable to look after their own basic needs, which has already been <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/disability/articles/coronavirusandthesocialimpactsondisabledpeopleingreatbritain/may2020">reported</a>. If the domiciliary sector and care workers are not supported or available to provide safe care through a second wave, people could be left even more vulnerable. </p>
<p>They would face increased isolation, <a href="https://www.bda.uk.com/resource/government-action-is-urgently-required-to-prevent-malnutrition-amongst-older-adults-due-to-covid-19.html">malnutrition</a>, reduced mobility and worsening dementia symptoms and wellbeing. They may also be unable to access <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/disability/articles/coronavirusandthesocialimpactsondisabledpeopleingreatbritain/may2020">medication and healthcare</a>. </p>
<p>For the domiciliary care sector, losing business <a href="https://www.cqc.org.uk/news/stories/sharing-insight-asking-questions-encouraging-collaboration-cqc-publishes-first-insight-document-on-covid-19-pressures">may ruin</a> many companies, and experienced carers would lose their jobs. Care may no longer be available when people decide they want it again and so they may end up in hospital <a href="https://ukhcablog.com/blog/homecare-in-the-time-of-coronavirus/">unnecessarily</a>, which will place <a href="https://lordslibrary.parliament.uk/research-briefings/lln-2020-0042/">more pressure</a> on these services. Or care providers may be staffed by people with less experience who are not able to provide as high a standard of care as before the pandemic. </p>
<h2>Get ready now</h2>
<p>Constant changes to already muddled COVID policies and regulations, lack of investment and minimal acknowledgement of the plight of the domiciliary care sector is compounded by the issues raised above. An ongoing pandemic, coupled with care home closures, may increase the risks to domiciliary care workers and the people they care for. </p>
<p>To mitigate the consequences of a second wave, it is crucial to ensure that domiciliary care providers, carers and service users are protected, valued and supported. Care sector structures should be helped to become resilient and there must be immediate support for infection prevention and control, testing, food and other support services for vulnerable people with care needs. A failure to do so will leave those in receipt of care, care workers and care and health systems at increased risk.</p><img src="https://counter.theconversation.com/content/141549/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Heather Catt receives funding from Public Health England and the UK Prevention Research Partnership. </span></em></p><p class="fine-print"><em><span>Elizabeth Dalgarno does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>People who use home care and their carers may be even more vulnerable during a second wave.Elizabeth Dalgarno, Lecturer, Healthcare Sciences, University of ManchesterHeather Catt, Clinical Lecturer in Public Health, University of ManchesterLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374582020-07-08T10:57:37Z2020-07-08T10:57:37ZCare homes have long been neglected – the pandemic has shown us how bad things are<p>Before COVID-19, there were around <a href="https://fingertips.phe.org.uk/profile/end-of-life">10,000 deaths</a> in care homes in England and Wales every month. Then, between March 27 and April 24 2020, the number <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/datasets/weeklyprovisionalfiguresondeathsregisteredinenglandandwales">more than doubled</a> to 23,113. </p>
<p>The <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases">Office for National Statistics (ONS)</a> later reported 17,422 deaths of care home residents from COVID-19 between the end of March and June 5, accounting for 47% of the total number of deaths caused by the virus.</p>
<p>So it is unsurprising that the pandemic has led to much greater interest in what happens inside care homes. As well as the significant increase in the number of residents dying, concerns have been raised about a <a href="https://www.bmj.com/content/368/bmj.m1280">lack of access to testing and personal protective equipment (PPE)</a>, the discharge of <a href="https://news.sky.com/story/coronavirus-sacrificing-the-elderly-care-homes-asked-to-take-covid-19-patients-11969661">coronavirus-positive</a> patients from hospital to care homes, <a href="https://thebristolcable.org/2020/04/bristol-coronavirus-dnr-whos-life-to-save-do-not-resuscitate-forms/">rationalisation</a> of the health care received, and a lack of clarity about the <a href="https://www.theguardian.com/world/2020/apr/14/uk-care-providers-allege-covid-19-death-toll-underestimated?CMP=share_btn_tw">numbers of residents</a> dying from COVID-19.</p>
<p>Even before the pandemic, the private ownership of most care home establishments isolated them from accessing appropriate training and support from <a href="https://journals.sagepub.com/doi/10.1177/0269216310387964">NHS professionals</a>, such as specialist nurses and palliative care teams. Some members of the care home sector <a href="https://www.theguardian.com/society/2020/apr/20/uk-care-home-bosses-call-for-help-from-medics-as-death-toll-grows">have since called</a> for doctors and nurses to be deployed to care homes to help manage the crisis.</p>
<p>Care home staffing is also a challenge, with <a href="https://www.ageuk.org.uk/documents/EN-GB/For-professionals/Research/The_Health_and_Care_of_Older_People_in_England_2016.pdf?epslanguage=en-GB?dtrk=true">vacancy rates of 11%</a> and a workforce that is <a href="https://www.skillsforcare.org.uk/NMDS-SC-intelligence/Workforce-intelligence/documents/State-of-the-adult-social-care-sector/The-state-of-the-adult-social-care-sector-and-workforce-2018.pdf">ageing, low paid and reliant on immigration</a>. This is coupled with the knock-on effects of shrinking local government adult social care budgets, meaning that the care home market is increasingly fragile. </p>
<p>For my recent <a href="https://doi.org/10.1017/S0144686X1900182X">research</a>, I spoke with residents of care homes about their experiences of living – and the prospect of dying – in them. </p>
<p>Many said they had disagreed with the decision to move into a care home, but their views were not listened to or considered. Despite paying up to £4,000 per month to do so, living in this environment is often associated with <a href="https://www.sciencedirect.com/science/article/pii/S0890406510000666">imposed routines and a loss of control</a> and <a href="https://www.sciencedirect.com/science/article/pii/S0890406510000666">independence</a>. </p>
<p>Despite this, some people I spoke to did have positive things to say. There was the 94-year-old man who clearly valued the efforts of the staff who care for him. He told me: “They sit on the bed and they have a good old natter and a laugh too, which is the best medicine. They pinch my sweets. But yes, we have a good laugh. This is a very happy place, actually.”</p>
<p>One 86-year-old woman, weighing up the pros and cons of where she received her care, explained: “At the moment I prefer care home to hospital because I feel perhaps a hospital is a bit impersonal – but on the other hand they tend to you quicker. But I wouldn’t like to be in a hospital now. The last time I [was] there I was thinking [the] care home would be more comfortable.”</p>
<p>Those residents will have seen major changes in the homes they live in over the last few months, with visits heavily restricted and staff wearing masks. GPs also switched to remote consultations, by telephone or video, which will also have affected the experience of some residents – such as planning for care at the end of life. </p>
<h2>Important conversations</h2>
<p>As a GP, <a href="https://theconversation.com/why-gps-and-patients-need-to-talk-more-openly-about-death-112345">I have seen firsthand</a> the difference it can make if care home residents and their families have the opportunity to have important conversations about their wishes and preferences for care at the end of life. Not everyone is keen, of course. Asked whether or not she discussed death and dying with her family, one 96-year-old woman told me: “No, I don’t speak [about death]. I’m not a person like that. I think my daughter knows me, she knows how I feel about things.”</p>
<p>Unfortunately, some organisations appear to have dispensed with a personal approach to these conversations since the pandemic. One GP surgery <a href="https://www.theguardian.com/society/2020/mar/31/welsh-surgery-says-sorry-after-telling-the-very-ill-not-to-call-999">sent letters</a> to vulnerable patients stating that they would like to complete DNACPR (do not attempt cardio-pulmonary resuscitation) forms on their behalf. Brighton and Hove Clinical Commissioning Group also <a href="https://www.bbc.co.uk/news/uk-politics-52155359">wrote</a> to all GP practices suggesting that all residents of the 98 care homes in that area should have a resuscitation plan in place.</p>
<p>On this particular issue, more open discussion is required about the reality of resuscitation following a cardiac arrest. This should include the fact that all cardiac arrests have an underlying cause and that resuscitation attempts will only be successful if this cause can be identified and reversed. </p>
<p>The underlying cause of cardiac arrests in older, more frail people is usually due to a range of factors and rarely easily reversible. The chance of them surviving a resuscitation attempt is very low. </p>
<p>Resuscitation, involving electric shocks to the heart and chest compressions, can be a brutal process, and not what most people would describe as a “good death”. It can be helpful to think about not attempting to resuscitate as allowing the natural process of death to occur peacefully and with dignity.</p>
<p>Peace and dignity are surely the things we would wish for anyone nearing the end of their lives. Yet our most vulnerable members of society have suffered greatly during this pandemic. </p>
<p>Care homes have long been neglected, partly due to widespread privatisation and low levels of funding for social care. We should all hope that the coronavirus crisis marks a turning point – and a change that means care homes are finally given the funding, staffing and support they so desperately need.</p><img src="https://counter.theconversation.com/content/137458/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucy Pocock receives funding from the National Institute for Health Research School for Primary Care Research. She is a member of the Labour Party.</span></em></p>The spotlight reveals that better funding and support are urgently needed.Lucy Pocock, GP Career Progression Fellow, University of BristolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1380722020-05-19T09:22:57Z2020-05-19T09:22:57ZThe eerily similar pandemic we could have learned from but didn’t<figure><img src="https://images.theconversation.com/files/335398/original/file-20200515-138606-1q8ino2.jpg?ixlib=rb-1.1.0&rect=194%2C0%2C4961%2C2709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cholera would often turn its victims’ skin a bluish grey.</span> <span class="attribution"><a class="source" href="https://wellcomecollection.org/works/vt5g3jxf">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span></figcaption></figure><p>In 1849, a cholera epidemic that was sweeping through Britain reached West Riding Asylum in Wakefield, West Yorkshire. The deadly disease soon spread through the wards. Searching for the source of the outbreak, the consulting physician eventually settled on an individual who had been admitted while ill. The doctor described this unfortunate patient as the “<a href="https://wellcomecollection.org/works/rcc64ksg?query=UNIVERSITIES%20AND%20COLLEGES%20-%20AD&page=40">unconscious messenger of death</a>”.</p>
<p>Over a century and a half later, a care-home owner in Devon – alarmed by the fact that local care homes could admit residents with COVID-19 – expressed his fears in a strikingly similar way. In early April 2020, the government issued <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/880274/Admission_and_Care_of_Residents_during_COVID-19_Incident_in_a_Care_Home.pdf">guidelines</a> that permitted taking in new residents even if sick. This, the care-home owner argued, would be “<a href="https://news.sky.com/story/coronavirus-sacrificing-the-elderly-care-homes-asked-to-take-covid-19-patients-11969661">tantamount to importing death</a>”. </p>
<p><a href="https://www.theguardian.com/world/2020/apr/28/uk-records-4343-care-home-coronavirus-deaths-in-a-fortnight">Care homes</a> are the epicentre of the COVID-19 pandemic in the UK. Compared to all other settings, they have seen the <a href="https://www.health.org.uk/news-and-comment/charts-and-infographics/deaths-from-any-cause-in-care-homes-have-increased">biggest relative increase in deaths</a> since the start of the outbreak. Most of the vast asylums of the Victorian era closed in the 20th century, as <a href="https://www.kingsfund.org.uk/publications/making-change-possible/mental-health-services">attitudes to treating mental health changed</a>. Yet there are haunting parallels to be seen. Responses to, and experiences of, an outbreak of disease at one of these asylums back in the 19th century are disturbingly resonant today.</p>
<p>Cholera, an acute diarrhoeal disease, claimed the lives of more than 100 patients at West Riding Asylum in 1849. Such was the scale of the tragedy that the consulting physician, Thomas Giordani Wright, was commissioned by the asylum’s regulators to investigate and account for this disaster. The result, <a href="https://wellcomecollection.org/works/rcc64ksg">a report published in 1850</a>, allows us to reconstruct the story of the cholera outbreak in minute detail. It is a story which foreshadows our own.</p>
<hr>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
<hr>
<h2>Cholera grips the asylum</h2>
<p>The 19th century witnessed a huge expansion in the number of asylums in England. </p>
<p>In 1808, the British government passed legislation that allowed counties to collect and spend taxes on building asylums for those unable to pay for private treatment for mental illness. While most counties didn’t begin construction until they were forced to by <a href="https://en.wikipedia.org/wiki/Lunacy_Act_1845">further legislation in 1845</a>. Yorkshire was quick off the mark. West Riding Asylum opened its doors in November 1818, initially with a view to accommodating 150 patients. By the middle of the century, extensions and a second building meant that more than 500 patients filled its wards.</p>
<p>Global cholera pandemics were a repeated problem throughout the 19th century. When the disease hit Britain in the autumn of 1848, Yorkshire was initially spared. But by September 1849, it had reached <a href="https://books.google.co.uk/books?id=hjM9AAAAIAAJ&printsec=frontcover&dq=Medicine+and+Society+in+Wakefield+and+Huddersfield,+1&hl=en&sa=X&ved=0ahUKEwjN7-iIhp3pAhXhThUIHTomCOcQ6AEIJzAA#v=onepage&q=cholera&f=false">Wakefield</a>. In his report, Wright conjures an image of the institution besieged, with “the spread of the pestilence all around the asylum”.</p>
<p>Some of those who had been attached to the asylum for a long time, like Wright himself, might have taken confidence from the fact it had escaped disaster during the previous cholera pandemic to hit England, in 1832. In 1849, sadly, it would not be so lucky. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=743&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=743&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=743&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=933&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=933&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334335/original/file-20200512-175262-t15xc9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=933&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/f2ypemp8">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In his report, Wright sought to understand how the disease had infiltrated the institution. He was doing so a few years before John Snow’s discovery that cholera was waterborne. Yet an inspection of both the drainage and ventilation did take place at West Riding Asylum; both were given a clean bill of health. Indeed, the inspectors – Messrs West and Dawson – were left to conclude that “the visitation, fatal as it has been to many, must be considered either as the immediate infliction of Divine Providence, or as dependent on causes of which nothing as yet is known”.</p>
<p>Wright looked elsewhere for causes. And in spite of his admission that “the laws of contamination are, in fact, little known”, he set his sights on one Elizabeth Fenton – his “unconscious messenger of death”.</p>
<h2>The hunt for ‘patient zero’ begins</h2>
<p>Elizabeth Fenton, a person with epilepsy, had been admitted to West Riding Asylum on 17 September 1849. She came from the nearby Gomersal Workhouse, where she had been for the past six years after her husband, a stonemason, abandoned her and their two children. Although her transfer had been recommended some weeks earlier, when the local official called at the workhouse to take her to the asylum, it took people at the workhouse by surprise.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=939&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=939&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=939&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1180&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1180&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334343/original/file-20200512-175241-1c8o7na.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1180&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The floorplan for West Riding Asylum.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/rcc64ksg">Wellcome Collection</a></span>
</figcaption>
</figure>
<p>Strokes of ill luck might, in part, explain the disastrous chain of events which followed. Two residents at the Gomersal Workhouse had died of cholera the night before Fenton was transferred; one of them normally slept in the same room as her. Yet authorities may have been lulled into a false sense of security by the fact that Fenton had not had direct contact with these residents before her transfer. She had suffered an unusually violent seizure that week, and so had spent most of her last nights in the workhouse restrained in a chair in another room. And the day before her transfer, she had been given a laxative to help relieve constipation. An early warning sign of cholera infection, diarrhoea, was thus concealed.</p>
<p>By the evening of her first day in the asylum, Fenton had developed symptoms. She was isolated immediately, as it had become clear that an outbreak was underway in Gomersal Workhouse. Her room was locked, and access restricted to a select few. But within a week, four more women had fallen ill. From that point on, the disease spread like wildfire through the female as well as male patient populations of the asylum.</p>
<p>Since the male cases were known not to have had any direct contact with any of the female cases, and the original four women were not even thought to have seen Fenton, Wright was stumped to explain whether the mode of transmission was “gaseous or solid, material or immaterial, vegetable or animal, magnetic or electrical”. </p>
<p>But he was firm in his conclusion that “infection was in some way brought into the asylum by that patient”. He cinched his argument by referring back to the 1832 pandemic, which the asylum had escaped unscathed. The only difference, he argued, between the two contexts was that no new patients from infected districts had been admitted in 1832, whereas in 1849, they had: Fenton. Case closed.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334676/original/file-20200513-156651-19wbele.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">West Riding Asylum eventually closed its doors in 1995.</span>
<span class="attribution"><a class="source" href="https://www.countyasylums.co.uk/stanley-royd-wakefield/">County Asylums</a></span>
</figcaption>
</figure>
<p>Yet Wright pursued this line of investigation further, with prosecutorial zeal, by turning his attention to Gomersal Workhouse. Fenton had brought the disease from Gomersal to West Riding Asylum – but how, in the first place, had it arrived at Gomersal? </p>
<p>From the medical officer at the workhouse, Wright learned that on 6 September “a dirty Irish woman, and her four children, were brought into the workhouse”. Showing signs of cholera, they had been taken to the workhouse hospital, where the mother had died just hours after arrival. One of her children died “a day or two after”; the exact timing was not thought worth recording. And just a day before Fenton was transferred to the asylum, two other women at the workhouse died.</p>
<p>As we know all too well from COVID-19, Aids and other recent pandemics, the hunt for the first person to fall ill – known as “patient zero” – collides with other vectors of stigmatisation. In the case of COVID-19, this has been clear above all in the horrifying rise in <a href="https://www.hrw.org/news/2020/05/12/covid-19-fueling-anti-asian-racism-and-xenophobia-worldwide">anti-Asian racism and xenophobia worldwide</a>. </p>
<p>By 1849, the arrival in England of hundreds of thousands of Irish displaced by the Great Famine had contributed to wider anti-Irish sentiment, cementing a prejudicial association with poverty, dirt and disease. Forced into desperate living conditions, <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)63368-8/fulltext">including dog kennels and cellars</a>, this was an association which drew vicious strength from the <a href="https://www.jstor.org/stable/pdf/23354141.pdf?ab_segments=0%2Fbasic_SYC-5152%2Ftest&refreqid=search%3Aca7bcc680c574475f259f962ebc4e364">staggeringly high death rates</a> among the Irish during times of epidemic disease. As well as being epidemiologically <a href="https://theconversation.com/patient-zero-why-its-such-a-toxic-term-134721">unhelpful</a>, Wright’s explicit identification of a local Irish patient zero fed into growing anti-Irish racism and a representation of the Irish as carriers, rather than fellow sufferers, of the disease.</p>
<h2>The human cost rises</h2>
<p>With cholera loose in the institution, the medical officers and attendants at West Riding Asylum tried to fight it using the full arsenal at their disposal: removal of patients to a separate cholera ward; improvements in diet – including “extra allowances of tea and brandy for supper”; fumigation of wards; and laundering of all bed sheets and clothes. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=718&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=718&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=718&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=902&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=902&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334422/original/file-20200512-82353-bolwx6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=902&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A Victorian cartoon lampoons the ineffective cholera treatments available at the time.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/veuzmq8z">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>But as in the current pandemic, there was no cure, no vaccine. By the end of the year, more than 100 residents had died of cholera. Nineteen had died in just a single day towards the end of October.</p>
<p>In what Wright evidently considered to be a small mercy, the patients “generally did not appear to be much affected by fear, nor were they aware of the extent of the mortality”. But just as in today’s care homes, for the staff of the institution, it was traumatic. “It was a period of awful emergency, and the consternation of all was increased by the fearful mystery of the pestilence, the rapidity of its attack, without previous symptom or warning, and the little more than failure of every effort, to mitigate its course, or avert its progress.”</p>
<p>Amid this horror, it is unsurprising – particularly, unhappily, to us now – that residents were not the only fatalities. On November 4 1849, Mrs Reynolds, the chief nurse of the ward set up to tend to cholera cases, died of the disease. </p>
<p>In a separate <a href="https://wellcomelibrary.org/item/b3031396x#?c=0&m=0&s=0&cv=0&z=-0.8814%2C-0.101%2C2.7627%2C2.0203">report in November 1849</a>, the director of the asylum quoted Reynolds as saying: “If I should die, I shall have the satisfaction on my death bed of knowing that I have done my duty.” Wright later wrote movingly of “her heroic and unremitting devotion to her duties” and “her kindness and humanity”. </p>
<p>Reynolds was not alone in being held up for praise. In 1851, the director of the asylum looked back on the service of all staff in these harrowing months “<a href="https://wellcomelibrary.org/item/b30314033#?c=0&m=0&s=0&cv=0&z=-0.8437%2C-0.0983%2C2.6874%2C1.9653">with gratitude and admiration</a>”. And while noting that “no pecuniary recompense can adequately remunerate such services”, he drew attention to the princely sum of £264 which had been distributed among staff by the visiting justices, and a further – unspecified but “very large” – sum disbursed by a visiting magistrate (there to oversee Wright’s investigation) in a private capacity. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/335397/original/file-20200515-138620-blys5m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Staff at another 19th-century asylum, the Royal Western Counties Institution in Devon.</span>
<span class="attribution"><a class="source" href="https://wellcomecollection.org/works/gm93f37u">Wellcome Collection</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>There is a poignant coda to this story, however. In contrast to the “substantial tokens of public approbation” the surviving officers and attendants had received, Wright used his report to draw attention to the sad inadequacy of Reynolds’s final resting place: a grave “without a mark to record her fate”. He pleaded with the magistrates and medical officers to make contributions so that her life and service could also be properly remembered.</p>
<h2>Were lessons learnt?</h2>
<p>Wright rounded off his report with a “lessons learnt” section – a genre with which we are likely to become all too familiar in the coming months and years.</p>
<p>While noting that changes to diet and fumigation appeared to bear some fruit, the lesson Wright was desperate to hammer home was the importance of “the precaution of not admitting into the asylum fresh patients from infected districts”. In that respect, his advice was much stricter than that issued by the Board of Health, the body charged with the control of epidemic disease, whose confident assurances – he suggested – had influenced people “to disregard all risk of communication”.</p>
<p>Wright concluded: “We have been fatally taught, that it is most important to use every possible vigilance to avert the approach of cholera; for, if it once find an entrance, no human resources are of much avail, to mitigate its intensity or abate its ravages.”</p>
<p>The colossal asylums of the 19th century may no longer be with us, but the parallels haunt us still. The risk to care homes was clear early in the contemporary crisis, <a href="https://www.thetimes.co.uk/article/sage-names-of-scientific-advisors-to-be-released-amid-cummings-controversy-727c2vfpp">according to chief scientific adviser Sir Patrick Vallance</a>. And the vulnerability of institutionalised populations was not only foreseeable; doctors during the 1849 cholera outbreak tried to pass down lessons to future generations.</p>
<p>Even before the discovery of germ theory enabled scientists to understand better how diseases spread, medical experts urged caution when it came to the admission of new patients into institutions filled with vulnerable populations during times of epidemic. Yet in 1849 at West Riding Asylum, as in care homes in 2020, the authorities have been slow to pick up on these dangers – with tragic results in these institutions for residents and carers alike.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
<ul>
<li><p><em><a href="https://theconversation.com/how-tattoos-became-fashionable-in-victorian-england-122487?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">How tattoos became fashionable in Victorian England</a></em></p></li>
<li><p><em><a href="https://theconversation.com/lockdown-lessons-from-the-history-of-solitude-134611?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Lockdown lessons from the history of solitude</a></em></p></li>
<li><p><em><a href="https://theconversation.com/what-will-the-world-be-like-after-coronavirus-four-possible-futures-134085?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">What will the world be like after coronavirus? Four possible futures</a></em></p></li>
</ul>
<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/138072/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Chris Wilson has received research funding from the Wolfson Foundation and the University of Cambridge. </span></em></p>There is a sad precedent of pandemic disease threatening the residents of care institutions – and of authorities not heeding the dangers.Chris Wilson, Lecturer in History, University of East AngliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1381782020-05-14T15:00:06Z2020-05-14T15:00:06ZGovernments must resist coronavirus lobbying and focus on long-term transformation<figure><img src="https://images.theconversation.com/files/334744/original/file-20200513-156633-vxplja.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4816%2C3056&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On Parliament Hill and at provincial legislatures across the country, politicians must resist pressure from industry and corporate lobbyists amid the COVID-19 pandemic.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Sean Kilpatrick</span></span></figcaption></figure><p><a href="https://www.nationalobserver.com/2020/05/01/news/ontario-allowing-secret-lobbying-amid-covid-19-critic">Reports recently emerged</a> that the Ontario government is quietly setting up an online portal where businesses can ask for regulation or rule changes to help them weather the COVID-19 pandemic. </p>
<p>The news seemed to confirm what many observers have suspected has been going on behind the scenes during the COVID-19 crisis — while media and public attention have been overwhelmingly focused on the pandemic, intense <a href="https://www.theguardian.com/environment/2020/apr/17/polluter-bailouts-and-lobbying-during-covid-19-pandemic">backroom lobbying</a> has been taking place on behalf of major economic interests.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334448/original/file-20200512-82397-11u94yy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tim McMillan, president and CEO of the Canadian Association of Petroleum Producers, at a news conference in Ottawa in February 2018.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>There have been reports of similar <a href="https://globalnews.ca/news/6830754/capp-justin-trudeau-laws-coronavirus/">intense lobbying</a> at the federal level, particularly by the oil and gas industry. </p>
<p>These efforts seem largely focused on restoring the economic status quo. In many cases, like those of the Canadian Association of Petroleum Products (CAPP), the goal seems to be to take the opportunity to convince governments to double down on existing economic strategies, effectively reinforcing the positions of already dominant sectors, stakeholders and corporations.</p>
<h2>Resisting pressure</h2>
<p>While, to its credit, the federal government <a href="https://www.cbc.ca/news/politics/pandemic-covid-coronavirus-oil-gas-alberta-climate-change-1.5536970">seemed to reject</a> the bulk of CAPP’s proposals for now, governments need to continue respond to this kind of pressure with caution.</p>
<p>Many of the demands being made by various industries have little or nothing to do with the immediate impact of the pandemic or responses to it. At the same time, the COVID-19 crisis has raised <a href="https://www.nationalnewswatch.com/2020/04/14/the-coronavirus-crisis-wake-up-call-for-an-economic-paradigm-shift/#.XpxLHpl7mox">major questions</a> about the viability of the economic, business and employment models that those lobbyists are arguing for a return to.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/returning-to-normal-post-coronavirus-would-be-inhumane-136558">Returning to 'normal' post-coronavirus would be inhumane</a>
</strong>
</em>
</p>
<hr>
<p>The pandemic has revealed serious <a href="https://theconversation.com/coronavirus-another-chance-to-transform-the-global-food-trade-136561">vulnerabilities</a> of key global supply chains that feed just-in-time delivery and inventory models, supported by workers in increasingly <a href="https://ipolitics.ca/2019/12/16/gig-economy-work-in-canada-is-growing-stats-can-says/">precarious contract jobs</a>. </p>
<p><a href="https://www.cbc.ca/radio/thesundayedition/the-sunday-edition-for-april-5-2020-1.5518735/why-the-invisible-workers-cleaning-up-covid-19-need-better-labour-protection-1.5518747">Those most vulnerable</a> have turned out to be critically important in maintaining food supply chains, health-care systems and the physical infrastructure needed for societies to continue to function and respond to the pandemic. </p>
<p>The need for more <a href="https://nursesunions.ca/position-statement-on-covid-19/">precautionary</a> approaches when it comes to responding to public health and safety threats has also been highlighted.</p>
<h2>Crises not erased by pandemic</h2>
<p>Longer-term global challenges, like <a href="https://www.ipcc.ch/sr15/">climate change</a>, the crises of <a href="https://www.un.org/sustainabledevelopment/blog/2019/05/nature-decline-unprecedented-report/">ecological sustainability</a> in the oceans and on land, and <a href="https://inequality.org/facts/global-inequality/">growing inequality</a> between the rich and the poor have not disappeared .</p>
<p>Rather, they’re at risk of being <a href="https://www.nationalobserver.com/2020/03/25/opinion/265-academics-trudeau-no-bail-out-oil-and-gas-response-covid-19">exacerbated</a> by governments in their response to the coronavirus. </p>
<p>Global communications networks have played a key role in facilitating responses to COVID-19, and have been central to the functional and social <a href="https://www.reuters.com/article/us-health-coronavirus-zoom/zoom-pulls-in-more-than-200-million-daily-video-users-during-worldwide-lockdowns-idUSKBN21K1C7">viability</a> of the lockdowns that have been implemented around the world. </p>
<p>However, their potential ability to manage the pandemic over the long term raises serious questions about privacy and government surveillance activities that will extend far beyond the end of the current crisis.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/digital-surveillance-can-help-bring-the-coronavirus-pandemic-under-control-but-also-threatens-privacy-135151">Digital surveillance can help bring the coronavirus pandemic under control – but also threatens privacy</a>
</strong>
</em>
</p>
<hr>
<p>In a situation where it looks as though physical distancing may need to continue for an <a href="https://www.cbc.ca/news/health/coronavirus-pandemic-end-1.5521710">extended period</a> — certainly until more widespread testing and contact tracing systems are in place, and potentially until effective treatments and vaccines are available — steps need to be taken to restore some basic accountability and oversight structures on governmental activities.</p>
<p>The live and virtual <a href="https://nationalpost.com/news/covid-19-scheer-says-parliament-to-reopen">reconvening</a> of Parliament was a good move in the right direction, as was Toronto city council’s first <a href="https://globalnews.ca/news/6883887/coronavirus-toronto-city-council-virtual/">virtual meeting</a> earlier this spring. A similar return by provincial legislatures is long overdue.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334771/original/file-20200513-156641-c2jinl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Canadian MPs are shown on a monitor during a virtual session of the House of Commons on April 28, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span>
</figcaption>
</figure>
<p>Other basic safeguards for transparency and accountability in corporate behaviour and governmental decision-making need to be restored. </p>
<h2>Ontario’s veil of secrecy</h2>
<p>Doug Ford’s government in Ontario, for example, <a href="https://www.ecojustice.ca/pressrelease/ford-suspends-public-participation/">has suspended</a> the public notice and comment mechanisms for environmental decisions and approvals under the province’s Environmental Bill of Rights for the duration of the emergency. </p>
<p>There was no evidence to suggest that the provisions were a barrier to the government’s responses to the crisis. If a problem arises, there are mechanisms to deal with emergency situations in relation to specific decisions in the legislation. Instead, there’s now a veil of secrecy behind which all manner of mischief unrelated to the pandemic may occur.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=443&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=443&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=443&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=557&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=557&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334775/original/file-20200513-156633-11a58sh.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=557&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ontario Premier Doug Ford speaks during his daily updates on COVID-19 at Queen’s Park in Toronto on May 12, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>Over the longer term, the pandemic has raised a series of questions that require answers.</p>
<p>Some are sector-specific. The catastrophic situation in care homes, which have emerged <a href="https://www.orilliamatters.com/around-ontario/ontario-covid-19-exploits-systemic-cracks-in-nursing-homes-to-devastating-effect-2262647">as the epicentre</a> of the pandemic in Canada, for example, will require <a href="https://marksw.blog.yorku.ca/2020/05/13/ontario-long-term-care-home-coronavirus-pandemic-disaster-the-case-for-a-public-inquiry/">formal inquiries</a> at the federal and provincial levels. </p>
<p>A fundamental rethinking of care models for the most vulnerable members of society must include major revisions to staffing, funding, oversight and inspection practices, and the roles of <a href="https://www.policyalternatives.ca/publications/reports/re-imagining-long-term-residential-care-covid-19-crisis">for-profit</a> operators in the system.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=429&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=429&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=429&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=539&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=539&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334777/original/file-20200513-156679-16mhmzp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=539&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Patient transport attendants disinfect a stretcher after working at the Madonna Care Community in Ottawa, a long-term care facility experiencing an outbreak of COVID-19, on May 3, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Justin Tang</span></span>
</figcaption>
</figure>
<p>More broadly, the situation has made it clear that steps will have to be taken to provide income and benefit stability and security in increasingly precarious workforces. </p>
<p>In little more than a decade, corporations around the world are <a href="https://www.washingtonpost.com/business/economy/a-guide-to-the-financial-crisis--10-years-later/2018/09/10/114b76ba-af10-11e8-a20b-5f4f84429666_story.html">seeking a second</a> massive bailout by governments — also known as taxpayers. In exchange, a demand for a system more balanced in favour of the interests of democratic governance, transparency, citizens and and the planet seems reasonable.</p><img src="https://counter.theconversation.com/content/138178/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Winfield receives funding from the Social Sciences and Humanities Research Council of Canada, the Natural Sciences and Engineering Research Council of Canada, and the George Cedric Metcalf Foundation.</span></em></p>The COVID-19 crisis has raised major questions about the viability of the economic, business and employment models that corporate and industry lobbyists are arguing for a return to.Mark Winfield, Professor of Environmental Studies, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1376712020-05-13T09:21:43Z2020-05-13T09:21:43ZCOVID-19 pandemic is our chance to learn how to reuse old medicines<figure><img src="https://images.theconversation.com/files/334114/original/file-20200511-49558-palxym.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p>It’s usually illegal to reuse leftover medicines in the UK for any purpose. But as a result of the coronavirus pandemic, the government has released <a href="https://www.gov.uk/government/publications/coronavirus-covid-19-reuse-of-medicines-in-a-care-home-or-hospice?utm_source=09d3c6e9-e7c7-4867-a197-d2a68e01f4be&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate">guidance</a> that allows this to happen in care homes and hospices, under very strict guidelines. </p>
<p>The guidance is to be welcomed. For the past two years, <a href="https://research.reading.ac.uk/research-blog/medicines-is-it-time-to-challenge-the-throw-away-culture/">we have been calling on</a> the government to consider changing the rules on reuse to prevent the massive amounts of waste that takes place when we throw away medicine. </p>
<p>The UK wasted an estimated £300 million a year of medicines <a href="https://discovery.ucl.ac.uk/id/eprint/1350234/1/Evaluation_of_NHS_Medicines_Waste__web_publication_version.pdf">in 2009</a>, £110 million of which related to medicines returned to community pharmacies for disposal. </p>
<p>People are more likely to <a href="https://link.springer.com/chapter/10.1007/398_2016_3">dispose of their unwanted residential medication</a> in the household bin or down the drain than return these to pharmacies, <a href="https://ehp.niehs.nih.gov/doi/full/10.1289/ehp.8315">contaminating</a> water and soil. Prescribed medicinal waste can also harm the environment by unnecessarily inflating our <a href="https://www.sduhealth.org.uk/policy-strategy/reporting/nhs-carbon-footprint.aspx">carbon footprint</a>.</p>
<p>A safe, sustainable system for reusing unwanted medication could make a huge difference in addressing these problems, beyond the current pandemic.</p>
<h2>What is medicine reuse?</h2>
<p><a href="https://onlinelibrary.wiley.com/doi/full/10.1111/ijpp.12391">Medicine reuse</a> is the idea that medication given to one patient can be taken back if it’s no longer needed and given to someone else to use instead. </p>
<p>Under normal circumstances, medicines dispensed in the community are not allowed to be reused, mainly because <a href="https://archive.bma.org.uk/collective-voice/committees/patient-liaison-group/resources/dispensed-but-unopened-medications">health officials worry that</a> drugs that come back from people’s homes will have declined in quality.</p>
<p>Medicines, after all, are not the same as other recycled goods — to work properly, the right amount of active drug is needed, but <a href="https://archive.bma.org.uk/collective-voice/committees/patient-liaison-group/resources/dispensed-but-unopened-medications">this could potentially decrease</a> if the medicine has been kept at the wrong temperature, or under too much light or moisture, away from the pharmacy.</p>
<p>The question of whether it is safe to reuse medicine is not an easy one to answer. We know <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/j.1365-2710.2009.01129.x">from our own work</a> on a small sample of tablets that if you take medicines out of their packaging and store them in hot and humid conditions for a month, there are at least some subtle changes. </p>
<p>But no one has ever fully looked at where and how medicines are generally stored when they leave the pharmacy. And we don’t actually know what (if anything) happens to medicines that are kept inside their original packaging. Because of this uncertainty, medicines returned to community pharmacies have to be <a href="https://psnc.org.uk/services-commissioning/essential-services/disposal-of-unwanted-medicines/">disposed of instead</a> of being reused.</p>
<p>Some countries including the <a href="https://www.ncsl.org/research/health/state-prescription-drug-return-reuse-and-recycling.aspx">United States</a> and <a href="https://givmed.org/en/">Greece</a> do operate medication reuse schemes, mainly for benevolent reasons – the idea being that suitable medicines can re-enter the supply chain and be re-issued to others who might not otherwise afford them.</p>
<h2>The environmental case for reuse</h2>
<p>Medicine shortages were a growing <a href="https://www.who.int/medicines/publications/druginformation/WHO_DI_30-2_Medicines.pdf?ua=1">global problem</a> even before the pandemic began.</p>
<p>In 2019 alone, the UK <a href="https://www.pharmaceutical-journal.com/news-and-analysis/news/confidential-government-documents-reveal-names-of-209-medicine-shortages-in-2019/20207603.article">identified supply issues</a> for 209 medicines, including heart medicines, anti-epilepsy tablets and treatments for cancer.</p>
<p>Now, the pandemic has added to an existing problem, by <a href="https://www.pharmaceutical-journal.com/news-and-analysis/opinion/comment/ways-to-safeguard-uk-drug-supplies-during-covid-19-and-beyond/20207897.article">reducing supplies</a> from overseas manufacturers while <a href="https://www.which.co.uk/news/2020/03/medicine-shortages-whats-going-on/">demand for medicines has naturally increased</a>.</p>
<p>The current government’s decision on the reuse of medicines, then, is a way of trying to deal with <a href="https://www.theguardian.com/commentisfree/2020/mar/19/will-coronavirus-lead-to-drug-shortages-for-the-nhs">drug shortages</a>. </p>
<h2>Medicine reuse in care homes</h2>
<p>What the <a href="https://www.gov.uk/government/publications/coronavirus-covid-19-reuse-of-medicines-in-a-care-home-or-hospice?utm_source=09d3c6e9-e7c7-4867-a197-d2a68e01f4be&utm_medium=email&utm_campaign=govuk-notifications&utm_content=immediate">government is suggesting</a> now is that care homes and hospices draw up <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881838/medicines-reuse-in-care-homes.pdf">standard operating procedures</a> in case they have to reuse some medicines. </p>
<p>The proposals are quite complex and need careful reading. If a medicine that is urgently required is out of stock, an alternative must be prescribed and dispensed if at all possible. If not, then the pharmacy can explore the possibility of reuse. </p>
<p>Importantly, the proposed medicine should no longer be needed by the original recipient, and both parties (or their representatives) must consent to the reuse. Added to this are <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881489/COVID-19_Infection_prevention_and_control_guidance_complete.pdf">measures to stop</a> the possibility of cross-contamination with the coronavirus during repackaging of the reused medicine.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/334116/original/file-20200511-30864-18uuma1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The new guidance on reusing medicine in care homes addresses a genuine need.</span>
<span class="attribution"><span class="source">from www.shutterstock.com</span></span>
</figcaption>
</figure>
<p>The new guidance addresses a genuine need within care homes and hospices which are already struggling on the frontlines of the pandemic, and where <a href="https://www.ft.com/content/aadf1825-4cad-4c8e-ad2d-5ecae186ca60">urgent demand for medication</a> is likely to be for the purpose of managing someone’s pain or breathlessness <a href="https://apmonline.org/wp-content/uploads/2020/04/priority-meds-for-end-of-life-care-290420-final-2.pdf">at the end of their life</a>. </p>
<p>Such a scenario is clearly an example where the benefit of reusing a medicine reasonably outweighs the potential risks.</p>
<h2>A more sustainable future</h2>
<p>It is vital that we learn from our experiences reusing medicine in care homes as we dare to look beyond the current pandemic. </p>
<p>At the moment, a registered health professional currently has <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/881838/medicines-reuse-in-care-homes.pdf">to inspect medicines</a> to make sure they are suitable for reuse. But whether completed in person or virtually, these checks can only provide a physical assessment, which does not guarantee the quality or amount of the medicines inside. So it will be important to find out how these inspections work in practice. </p>
<p>Our own ambition is to develop a <a href="https://www.mdpi.com/2226-4787/8/2/58">technology ecosystem</a> for the packaging of pharmaceuticals that will allow for the safe reuse of medicines in the future. This would involve creating a novel digital time temperature and humidity indicator to help with quality assurance of medicines. We have already developed a prototype using smart sensors which connect to the cloud to verify safety and enable the reuse of returned medicines.</p>
<p>This would provide an opportunity to explore medicine reuse not only during a pandemic but as a standard part of running a sustainable pharmacy.</p><img src="https://counter.theconversation.com/content/137671/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Parastou Donyai receives funding from Alzheimer's Society. </span></em></p><p class="fine-print"><em><span>Simon Sherratt works for the University of Reading as an academic, and has received research grants from the EPSRC .</span></em></p><p class="fine-print"><em><span>Rachel McCrindle and Terence Hui do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The UK government is allowing care homes and hospices to reuse leftover medicines during the pandemic. Here’s why that’s a good thing.Parastou Donyai, Professor and Director of Pharmacy Practice, University of ReadingRachel McCrindle, Professor of Computer and Human Interaction, University of ReadingRobert Simon Sherratt, Professor of Biosensors, University of ReadingTerence Hui, Postdoctoral research associate, University of ReadingLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1242562019-10-24T23:24:11Z2019-10-24T23:24:11ZTo die well, we must talk about death before the end of life<figure><img src="https://images.theconversation.com/files/298589/original/file-20191024-170458-fjk9xi.jpg?ixlib=rb-1.1.0&rect=51%2C68%2C5699%2C3759&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">In a research study, 84 per cent of residents and families who received a pamphlet about end-of-life choices felt encouraged to think about their future care.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>I would like to tell you an all-too-familiar story. It begins with a long-term care home resident, Laura, who has multiple chronic conditions and gets an infection that doesn’t get any better. </p>
<p>Her health has been declining for months, but no one has talked to her about her preferences for end-of-life care. In the absence of that knowledge, she is sent to the hospital where she undergoes stressful tests. </p>
<p>The story ends with Laura dying in the hospital, alone and frightened. Her family is traumatized, and so are the staff who have cared for her over the past year.</p>
<p>It’s a simple fact that 100 per cent of us will die. Conversations about our future health care and what’s important to us — <a href="https://doi.org/10.1136/bmj.c1345">called advance care planning</a> — have shown distinct benefits. </p>
<p>In fact, research shows that <a href="https://doi.org/10.1093/intqhc/mzw060">as many as one third of seriously ill, hospitalized older people are receiving invasive treatments they don’t want at end-of-life</a>, because no one has talked to them about their wishes for future care. This is true even in long-term homes, where the average lifespan is less than two years. </p>
<h2>Pamphlets help stimulate conversation</h2>
<p>How do we change those statistics and give our older people the care they want — and deserve? My team’s research has focused on answering that question over the past six years.</p>
<p>We recently developed <a href="https://www.chpca.net/projects-and-advocacy/projects/strengthening-a-palliative-approach-in-long-term-care-spa-ltc-project.aspx">a series of pamphlets</a> and distributed them in long-term care homes to try to get the conversation started. </p>
<p>The pamphlets were disease-specific (for example, focusing on dementia), and included information about life-limiting illnesses, what to expect and tips for talking about wishes for the future. </p>
<p>In our study, 84 per cent of residents and families who received a pamphlet felt encouraged to think about their future care and 70 per cent felt clearer about what to talk about.</p>
<h2>Planning death is a great relief</h2>
<p><a href="https://journals.sagepub.com/doi/10.1177/2333721417747323">Moving from thinking to discussion, however, was a different matter</a>. Family members worried that bringing up the subject would destroy hope. Residents thought they should protect their families from thinking about their death. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/298607/original/file-20191024-170481-mjyf1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Care home staff are essential to supporting conversations with residents about end-of-life planning.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>And many long-term care home staff indicated that <a href="https://doi.org/10.1016/j.jamda.2018.11.009">they did not feel trained to participate in these conversations</a> — in fact, only 21 per cent handed out the pamphlets, preferring instead for families or residents to take them from a display board.</p>
<p>Encouragingly, the 56 per cent of residents and families who did have conversations after receiving a pamphlet expressed great relief. A typical response from families was: “It makes it easier for me right now because now I don’t have to guess.”</p>
<h2>Death is taboo, globally</h2>
<p>The problem goes beyond long-term care homes. <a href="https://www.advancecareplanning.ca/acp-news/advance-care-planning-canada-releases-new-national-poll-2019/">A striking 93 per cent of Canadian participants in a recent poll think it’s important to communicate their wishes for future care</a> should they become seriously ill, but only 36 per cent have actually done so. </p>
<p>That may seem shocking. But according to the World Health Organization, <a href="http://www.euro.who.int/__data/assets/pdf_file/0017/143153/e95052.pdf">Canada is actually ahead of most European countries</a>. </p>
<p>Clearly, talking about death and the end of life is still <a href="https://www.ncbi.nlm.nih.gov/pubmed/28062339">taboo around the world</a>.</p>
<p>Informational resources such as our pamphlets can be a great first step in helping all parties gain clarity on what to be thinking and talking about. But because residents and families tend to protect one another, staff need to take more active roles in supporting such conversations. </p>
<h2>Care home staff need training</h2>
<p>That means we need to <a href="https://doi.org/10.1186/s12904-017-0207-y">clarify roles and provide the necessary training to support long-term care home staff</a>, especially those who develop strong relationships with residents.</p>
<p>We have <a href="https://www.canada.ca/en/employment-social-development/programs/seniors-action-report.html">an aging population</a>, and thanks to technological advances, more of us are living longer with frailty and chronic conditions. We need to find ways to communicate what’s important to us, so that we receive the care that’s right for us.</p>
<p>I would like to be able to tell you a different story. It begins with a care home resident, Sam, who gets an infection and is not getting better, even with antibiotics. </p>
<p>Sam has been living with multiple chronic conditions for some time and his family knew frequent infections could be a sign that the end of life was near. The family also knew that he wanted to die in the long-term care home and not in a hospital — because they had talked about this when he was healthier and could communicate his desires. </p>
<p>Sam dies, but with dignity and in peace and, most importantly, in keeping with his own wishes.</p>
<p>[ <em><a href="https://theconversation.com/ca/newsletters?utm_source=TCCA&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=expertise">Expertise in your inbox. Sign up for The Conversation’s newsletter and get a digest of academic takes on today’s news, every day.</a></em> ]</p><img src="https://counter.theconversation.com/content/124256/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tamara Sussman receives funding from The Canadian Frailty Network and the Canadian Institues of Health Research. </span></em></p>The seriously ill and their families often want to protect each other from thoughts of death. Conversation about end-of-life choices are, however, essential to a good death.Tamara Sussman, Associate Professor, School of Social Work, McGill UniversityLicensed as Creative Commons – attribution, no derivatives.