Monday, 4 May 2020

Care Home crisis

One of my regular roles as a GP was to visit and look after patients in the local care homes. As the workload built up over my career, we decided to start visiting the homes on a regular basis to do preventative work and in doing that got to know the local homes quite well. 

In my experience they were run with great compassion and cared for people with very challenging condition, often with amazing dedication and humanity. Unsung and underpaid heroes!

When COVID arrived I was aware of the dreadful inevitably of its spread into care homes, and that protective equipment and resources, concentrated in the hospitals in the first instance, would leaving those working in the community and their patients vulnerable.

It is very difficult for homes, who have been unable to tell if their unwell patients are infected or not, and also have poor supplies of protective equipment to needed to care for them while in isolation. They also have to deal potentially contagious survivors returning from hospital.

Worryingly, as reported in the excellent Bart's MS blog, even well equipped nursing homes in the US were unable to stop the spread of COVID, and that was with adequate levels of staff and equipment.

So it's a real problem for our care home sector. Some background:

According to a recent government review, interestingly written by the "Competition and Markets Authority" there are about half a million people in care homes in the UK with a total "worth" of £16 billion a year.

Only 5% of homes are provided directly by the state.  41% of residents fund themselves, 49% are paid by local authorities and 10% funded by the NHS. 

For information, the average cost for self-funders was £846/week, and local authorities pay £621/week.  This means that homes relying on public funding are already charging 25% below what is considered to be the going "market rate". Profits are squeezed in these homes, and with COVID this has pretty important implications.

There are 5,000 different providers 11,300 care homes. Importantly, 80% of the owners operate one home only and are likely to have very little financial resilience. 

The homes usually operate at 90% capacity or more, and with falling revenue and fixed costs, tend to make a loss if this falls below 80% or so. Those running at a loss will go to the wall. Even bigger concerns such as Southern Cross, operators of 750 homes with 31,000 residents went bust in 2011.

With austerity and cuts in funding for Local authorities sources of source of income for the majority of homes have been squeezed for some time, often leading to the need for minimum staffing levels and low pay for the staff.

Looking at the weekly ONS data of April17th there had been 3096 deaths in care homes in just the preceding week. In other words 16% of all COVID deaths were taking place in this vulnerable 1% of the population. The figures are likely to rise as the weeks roll by.

So with COVID now claiming so many lives in the care home sector, is the financial crisis now just a few weeks away? Will forced closures add further trauma to the already tragic events experienced by so many residents and staff.

The government has paid out over £2bn to keep nursing homes going, though as I write much of this remains locked up in local authorities, who are no doubt struggling to organise this aspect of the bail out in addition to their many other parallels crises

The lost revenue to nursing homes for the week up to April17th was £2m so the £2billion is is a useful lifeboat, once it's properly launched. However, it is unlikely to be enough in the long term to leave the sector unchanged. How will nursing homes adapt to lower occupancy rates and will they  survive with running costs exceeding revenue?

Might this lead to a total reconfiguration of the sector? The high death rates will leave many homes in debt, the smaller family run homes most likely to suffer first. My worry is that this will indeed lead to their closure in favour of the giant providers with tiny but expanded economics of scale, operated by equity companies and others? The market solution! 

Will provision from more robust and stable local authorities fill the gaps? Will we find better ways of supporting families to care for their elderly relatives beyond the current pittances of attendance and carers allowances? Better early, pro-active care could save costs in the long term, as well as that old nutmeg of more active, effective policies to prevent illness and maintain health and well-being. Spending now saves spending more later. 

Could the bail-out of the banking sector in 2008 be a model? Buying out parts of the nursing homes, effectively becoming private-public partnerships? I feel an advantage of this could be to reduce the need for external oversight as this could potentially be performed by local authorities. Might such local arrangements be less expensive and overbearing than the Care Quality Commission, which in my experience frequently caused much anguish to and even destabilised local care homes care homes.

I cannot see the present government being keen, but as with the banks, but it is an option. 

After COVID19 the challenge will remain for us as a society to determine how we look after the elderly, and indeed how we look after those who care for them. 

This is another of our modern dilemmas being laid bare by the pandemic. 


  1. CORONA POSITIVE ELDERLY are being placed back into care homes !! This is mentioned in passing in this blog, but shouldn't this be flagged up and properly addressed ? Like - I can self isolate for the next 20 years and it isn't going to help the vulnerable old and weak many of whom are in those care homes WHEN THIS IS HAPPENING ! How can you advocate Lockdown, and Track n Trace and all the measures we take, (to supposedly be protecting the really vulnerable from catching Covid) and then not flag up that the whole exercise is totally ruined by actually placing Covid carriers directly INTO the care homes. And 'Mistakes' does not cut it for me.
    Link to The Guardian article RE: Opposition grows to guidance saying residents who tested positive must be readmitted (to care homes)

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    1. Thanks for your comments on the post. It's a little dated and I hope for better things for care homes this winter. We shall see. Thanks again.


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