The Care Home Conundrum

The Care Home crisis rumbles on and probably won't be helped by giving care home workers a shiny new badge.

However, practicality trumps all the noise being generated.

The simple fact is, that almost no care home residents go out into the community in normal times, so they really shouldn't get infected. However, its well known from my experience that Norovirus makes regular visits to care homes in normal times.

The simple fact is, that its not the residents getting infected by themselves its people taking the virus in to them.

We know that most care homes banned visitors and non essential medical visits before the lock-down actually occurred so that 99.9% of external contact with the community was second hand via the carers themselves.

Therefore the outbreaks are being caused by carers catching the virus when they are outside the homes and then taking it in and passing it to residents when they go in.

So what can be done about that?

You could of course test all the carers, but according to my research there are 1.6 million care workers in the UK. We have a capability at the moment to do just shy of 20,000 per day, so at the current rate, to test every care worker ONCE would take 2.2 years.

Even if Hancock was to hit 100,000 tests per day it would still take 160 days to test all care workers ONCE and that's assuming we don't test NHS workers or patients admitted to hospital at all.

So unless there is a very sudden change on the number of tests available that isn't in any way an answer to this problem and that's before you start to address the issue of the people to carry out the tests and the lab capability to process them. Even on Germany's capability of 160,000 tests per week, its nowhere near enough.

Then, even having tested a care worker once, it just means they are positive or negative at that time. They may be super-spreaders and be positive but test negative or they may be in the early stages of infection and test negative when they are positive.

So, at the very best, any testing capability is merely going to move the bullet from the first chamber to the second. in the game of Russian Roulette.

PPE 

Again, this is by competition with the NHS, do you want to take it away from the NHS to give to care homes?

Logically in terms of preventing deaths, that's just not going to work, you'd just swap near certain deaths in care home residents and add to that younger fitter people who will die and of course kill mass numbers of doctors and nurses we can't easily replace.

The next question is - would PPE really work in care homes?

The vast majority of interactions in care homes are close quarters interactions of a "personal" nature. A simple face mask (high quality) may reduce the amount of exhaled virus but if a carer is infected then either the mask needs to catch all the virus breathed out (which i don't think it does) and if it does it must accumulate in the mask.

So yes, this would reduce the risk per personal interaction, lets say tenfold, but given the number of interactions per day, its still just a delaying tactic rather than a solution. One infected care worker has, due to the number of "two person jobs at close quarters" has the ability to infect pretty much every resident in a single shift and even with the best PPE, probably within a week.

But as we know, many care workers are off sick, even if it was by general population levels, care homes are short staffed at normal times and when you add onerous robing and disrobing to a single interaction the time per interaction multiples by a factor of three, so therefore you need three times the normal staff just to carry out the normal workload.

So high quality NHS "aerosol generating procedure" level PPE simply isn't practical even if you could get it.

Social Distancing

As the infection in care homes is undoubtedly coming from staff, and staff often have to work in pairs and at close quarters with the resident, that just isn't going to work. 

So when you consider all the potential preventative measures, none of them work and most of them at best merely delay the inevitable transmission.

Moving Infected Cases To Hospital

Many residents have very complex health needs and of course are very old. Their chance of survival in hospital is as near as nil as you can get. There are some that are physically quite fit and the decision should be made on the basis of their prior fitness. Just yesterday a 106 year old survived and was discharged, so age itself is not a disqualifying variable in itself.

But it must be remembered that these people are in care homes for a reason, dealing particularly with dementia patients in hospital is very difficult particularly if they are mobile.

You can take the approach "well I've paid for it, so you'd better take me" but that isn't the basis of NHS care, its a balance of the likelihood of a good outcome against the best interests of the patient overall and of course the cost.

The NHS doesn't treat you at any price, if it did NICE wouldn't exist. You have to take the likelihood of success and set that against the trauma you are going to put people through in their final days.

Sadly, some common sense does need to be applied.

For all the above reasons, I've run out of road on what I think the government could in all reality do better.