Two important new facts emerged from the Downing Street coronavirus press conference on Easter Monday. The good news came from Sir Patrick Vallance, the Chief Scientific Adviser. He estimates that the transmission of Covid-19, measured by the reproduction number (known as R), has fallen below 1 “in the community”. This means that social distancing has reduced the average number of people that each carrier of the virus infects to fewer than one. This is the crucial level at which the pandemic begins to peter out. Sir Patrick’s optimism is borne out by the flattening curves for new cases, hospital admissions and maybe even deaths.
But the good news came with a caveat. “In the community” includes most of us, but not those in hospital or, most importantly, those living in care and nursing homes. On the latter, the Chief Medical Officer, Chris Whitty, had some bad news to deliver. In the past 24 hours alone, he said, 92 care homes had reported cases of coronavirus, bringing the total figure to 13.5 per cent of all those in the UK, which equates to about 2,200 homes. These statistics reveal a dangerous second front in the pandemic which has hitherto been overshadowed by the focus on the NHS.
Well over 400,000 mainly elderly people live in care homes and many more are cared for in their own homes. All are extremely vulnerable, but the spread of Covid-19 in these sectors has been largely invisible. Reports from care homes suggest that the numbers dying there are already significant: 275 are known to have died, but the true figure may be much higher. We will know more today when the ONS statistics are published.
Several homes have reported serious outbreaks: most recently one in County Durham run by Care UK had 13 deaths. If deaths in a significant proportion of the 17,000 care homes were to rise to double figures, the numbers could run into tens of thousands and dwarf those dying in hospital. The allegation by a whistleblower on Channel Four News that doctors are routinely omitting Covid-19 from death certificates suggests that the true scale of the pandemic may have been underestimated.
What is certain is that testing and PPE equipment have been lacking outside NHS facilities and those working in care homes feel strongly that, as usual, social care is the Cinderella of the system. There is no evidence of any conspiracy, official or unofficial, to downplay the mortality of those in care. It is simply that pressure to free up beds in hospital has meant that care homes have been expected by Public Health England to take in hospital patients who may be infected. Care home providers say they have been told that they must readmit residents who have been in hospital with Covid-19. The interests of other, healthy residents are, they say, sacrificed for the sake of those who may be sick or dying.
These distressing developments feed the strong and widespread suspicion that Britain’s response to coronavirus is vitiated by ageism. The NHS is already using a scoring system known as the “clinical frailty scale”. Originally developed at Dalhousie University in Canada and adopted here by Nice, the scale helps clinicians — a term which includes nurses, care assistants and therapists as well as doctors — to decide whether those over 65 who fall ill with the virus would benefit from intensive care, or should be offered palliative care instead.
The cutoff is set at eight points. The scale automatically scores any patient aged 71-75 four points, plus a likely three for frailty. Such common conditions as high blood pressure, recent heart or lung disease or dementia score further points. Elderly people have long been encouraged to decide in advance whether they wish to be resuscitated, but advance care plans should never be agreed with patients or their families under duress. Professor Mayur Lakhani, an eminent palliative care specialist, appeals to doctors in the Times today: “We must dispel the idea that advance care plans are a way of denying treatment.” He is right that intensive care often has a very small chance of success in the case of severely frail patients, but he adds: “Functional status and not age alone is the key consideration.” In other words: doctors have a duty to be objective about old age.
The present tendency to play down deaths of those in care ignores the fact that many old people have a good quality of life. To their families, if not to the authorities, they matter — and so does their need to die with dignity. As the late Cicely Saunders, founder of the hospice movement, said: “How people die remains in the memory of those who live on.”
This pandemic will leave many legacies: from an economic slump, that we must hope will be short-lived, to shifts in work and leisure habits or altered attitudes to the natural and urban environment; these may last much longer. One change that may well be permanent will be to our view of old age, death and dying. Covid-19 has shone a light on the places where so many of our elderly relatives spend their twilight years. Residential institutions have a vital place in the ecology of care, but they should never be an automatic choice for those who could be looked after better in their own homes. The problem of social care in an ageing society has been shelved by successive governments, but it has now become urgent. If, as the Prime Minister says, the NHS “is powered by love”, what is powering its poorer, neglected sister service? We owe it to our parents and grandparents, those we like to call our “loved ones”, to look after them far better than we have done.