With the onset of winter and a second wave of coronavirus upon us, CHP asks National Care Association (NCA) executive chairman, Nadra Ahmed OBE, if the care home sector is now better prepared to deal with the pandemic?
Speaking at the beginning of October following the launch of the Government’s Winter Plan for Social Care, CHP began by asking Nadra if lessons had been learned from the devastating impact of the first wave of the pandemic.
“I think that providers have certainly learned some really strong lessons but whether government have is, I think, slightly questionable,” Nadra said.
Clearly still angry about the lack of planning for the sector up to the first wave, Nadra said care homes needed confidence in government this time around but the omens were not good.
“We need confidence in policymakers who are making these decisions but we don’t have that because things are still not going completely right,” Nadra told us.
“I think the PPE element has been resolved to a degree but providers are still going to have to make sure they have sufficient supplies for their services and pay for the extra required.
“We called very early on for a VAT exemption on all PPE and it was granted and then extended to the end of October, but we believe it should be further extended as a measure of support for all providers. I think the announcement of free PPE in the Winter Plan is a great headline but we know that we are still going to need to buy our own to top-up so we need to have the VAT exemption extended.
“The free element of PPE is welcome because its cost has left a number of providers on the brink of financial viability because they were spending huge amounts of money on it.”
NCA research earlier this year revealed that 70% of members were worried about their financial viability at the height of the pandemic, though Nadra said the group’s latest survey had shown this had come down to 67%.
When asked how much funding had come through to providers, Nadra singled out the Infection Prevention Control Fund (IPC), which had been particularly helpful with staffing costs.
“I think the IPC is the only fund that has actually reached the providers despite the fact that it was laden with huge challenges in the guidelines and the bureaucracy that’s involved and the interpretation of it by individual LAs,” Nadra said.
She said it had been “heart-breaking” to see 152 local authorities interpret funding guidelines in different ways, adding overall funding for the sector during the pandemic had been “abysmal” with the government’s much-vaunted £3.2bn having failed to reach providers in any meaningful way.
“The government ought to stop using the £3.2bn figure because it’s a well sculptured lie,” Nadra said.
While conceding a minority of areas had done “really well” with funding, she said the vast majority had not benefited significantly, “it feels like a classic postcode lottery”, she added.
As the sector enters another dangerous phase of the pandemic, testing has been highlighted as a key line of defence for providers but Nadra was again scathing in her assessment of the Government’s response.
“Testing has been a disaster,” Nadra told CHP. “There’s been over promise and under delivery consistently and that’s where the confidence in what we’re told and what actually happens is eroded.
“We go into our residents’ homes to deliver care so we have to be able to provide them with enough confidence to know that the environment they live in is safe and people coming into that environment are being tested to make sure that they’re not bringing anything in.
“How do we do that when the testing regime is so chaotic?”
The NCA boss said testing would be the single most important question when looking back at what went wrong with the Government’s handling of the pandemic.
Despairing of the Government’s failures to deliver regular and effective testing, Nadra said some members were being forced to take matters into their own hands and approach private providers and pay for tests.
She said test results still took on average between four to six days to come back with some taking up to 10 days.
“It’s the time scale that has been a real problem because if you’ve got somebody who’s been tested do you then keep them off work until the result comes back if they’ve got no symptoms? And if you get an inconclusive result do you have to test again and wait again?” Nadra asked.
“We can’t even have confidence that the test results are accurate. That just adds to the anxiety that we’re working under.”
While an increase in care home outbreaks had resumed at the end of September and into October, Nadra said providers had learnt the lessons of the importance of an early lockdown.
“Our members are locking down again and that’s causing different issues and challenges,” she reflected.
“I think a lot of providers are finding it extremely difficult to maintain the safety of their staff and residents without actually creating that lockdown scenario.”
Nadra highlighted concerns amongst providers over district nurses and CQC inspectors coming into care homes untested.
“It’s a complete contradiction saying that you’ve looked after the sector from the very beginning and at this point on the edge of a second wave or in into a second wave saying we don’t think people coming into care homes need to be tested,” Nadra argued.
The NCA head highlighted how restrictions on staff movement between homes stipulated in the Winter Plan were placing further staffing pressure on providers. Nadra pointed out the sector still suffered from a more than 110,000 staffing shortfall and predicted more vacancies would appear during the second wave.
“Providers want to over-staff now because that’s one of the important lessons they’ve learned and the IPC money can be used to support some of these arguments but where are we going to recruit the people who are going to fill these roles?” Nadra asked.
Given this context, Nadra said the current stance on access to the immigrant workforce by the Government was deeply unhelpful.
“The Home Office and Home Secretary feel we ought to be looking at the domestic population to fill our vacancies,” Nadra said. “God know what Ms Patel thinks we do normally!
“It’s patronising to think that providers immediately go to a migrant workforce. It’s an absolutely ridiculous assumption because the first port of call for any provider is to look at the local workforce. That’s what we do because that’s always the best and preferred route.”
The NCA head also noted that Home Office migration policy had not been supportive of social care recruitment and echoed the Migration Advisory Committee’s call for senior care workers to be added to the shortage occupation list.
Nadra said the image of social care had been so damaged over the years that people did not see care as a career pathway.
She added that endemic low-wages in the sector could not be addressed as they were inextricably linked to the low fees paid by local authorities and other commissioners.
“You can’t keep blaming providers and totally ignore the fact that LAs fees are well below what they need to be to enable better pay,” Nadra stressed.
She said the sector had attracted criticism for charging weekly fees of £1,400 and asking for PPE but pointed out that the vast majority of providers, including her members, were struggling to remain viable on fees typically of £550-650.
“We have always paid for PPE,” Nadra highlighted. “The point is that we could not access it through the pandemic and what we could access was subject to price hikes.”
She noted the challenge for the sector and for Government was how to attract people who had sadly been made unemployed during the pandemic.
“We have to have people who have the aptitude for the job and who are willing to be trained and stay with us,” Nadra said.
“There’s been promotional image building through the clapping for social care initiative and people appreciating what social care providers do but that’s very quickly forgotten when it comes to making a sustainable option moving forward.
“There has to be a career progression and there has to be a tangible methodology towards a pathway leading to all sorts of other careers as well, including nursing or physiotherapy, administration or whatever it might be.
“I think the one thing that we forget is there is a little village within the care homes we create and within that you have chefs, cooks, housekeepers, gardeners, maintenance people, admin and carers, and they’re all working towards the same aim and the same objective and that is about making people safe and happy at a time when they’re most vulnerable. So the career pathways are there, it’s about now making sure that we formalise them in a way that we can move forward and make social care an option that leads to pathways of lifelong learning.”
When asked if she had seen much evidence of people coming into care from other sectors such as hospitality, Nadra said it was too early to judge. She also noted the problem of people coming into care on a temporary basis during the pandemic and then returning to their professions.
“There were some people who were coming forward in localities to work in care services but as soon as lockdown eased off they went back to their normal jobs in retail or whatever so I think it’s got to be this retention issue that has to be addressed at the same time as recruitment,” Nadra stressed.
When looking at some of the challenges facing providers as outbreak levels ramp up over the winter months, CHP asked Nadra what her advice was for members being offered substantial financial incentives by local authorities to take COVID positive patients from hospitals.
“There are concerns about people being discharged out of hospital into care homes and if care homes are prepared to take them they need to be absolutely clear that they can isolate these people for a period of time away from the rest of their residence,” Nadra stressed.
“We’ve got the indemnity insurance issue that providers need to look into very carefully before they start signing documentation to enable that to happen and if that is not in place then they need to be asking to be indemnified by whoever is issuing that contract and that would be either LAs or the NHS.”
Nadra also called for providers to be given the same insurance indemnity offered to healthcare providers to mitigate the risk of taking COVID positive patients.
She emphasised that an exit pathway was also required so that providers were clear on where people entering services would move onto safely.
“From a provider representative perspective, I would say they need to be absolutely clear about what they are committing themselves to and how the risk to their businesses is going to be mitigated,” Nadra argued. She also noted the additional staffing pressures that taking COVID positive patients posed for providers.
With providers having now returned to lockdown, the NCA chief said maintaining physical links between residents and their families was one of the single most challenging questions facing the sector.
“We know the importance of visits,” Nadra said. “We know how important it is. When somebody comes into care services it’s a tripartite arrangement between three people. It’s the resident at the top of the pyramid and then it’s the caregiver and the family, and together we enable the best possible experience of care we can. So when you take away the family, you’re creating a single line of trajectory and I think that is difficult for the family member who’s not able to visit and it’s difficult for the resident who may not be able to understand why they are not visiting.
“Of course lots of our residents if they’ve got dementia forget that their loved ones have been but that doesn’t stop that visit being really important and it’s really difficult for the caregiver because they suddenly have to fulfil that part of that family’s crucial role.
“It’s not something providers are enjoying because they would much rather have a more open environment where people can come in because you can visibly see the mood of individuals lifting when they’ve had a relative and friends visiting.
“It’s not something providers want to do but we have guidance in place that tells us how and when we can enable these visits to happen.”
Nadra said the vagueness of Government guidance left providers exposed to insurance issues should something go wrong, which in turn, had led to some feeling the need to go even further in their restrictions.
“We are being labelled as the bad guys in this but it’s actually all we can do to make sure that we follow these guidelines but also that we enable as much contact as we possibly can,” Nadra noted.
“When we talk about robots and technology and the way people can stay in touch and all this new modern technology, at the end of the day all anybody ever wants is physical contact during a visit and you cannot replace that.”
When asked whether she was confident that providers were in a better place to withstand the pandemic than in March, Nadra said she remained concerned.
“I think the experience we’ve had will make us more agile to respond but I believe without testing being where it needs to be and my slight fear around access to additional PPE and funding, I’m not sure whether I’m more confident,” she reflected.
The NCA head noted the dangers that some “battle fatigued” providers may fall by the wayside because they cannot afford to lose more residents to the pandemic or carry the number of vacancies they have.
“I think we’re in a better place only because of the experience and the fortitude of our workforce,” Nadra observed.
“The sector has been absolutely outstanding in its response to the first wave when they were completely abandoned so I feel that now we are a bit better prepared but there are still external factors that have not been resolved and they need to be resolved for us to be able to be really confident.”
Looking longer term, Nadra said the need for real social care reform remained the fundamental issue facing the sector.
When asked what she would like to see in the reforms, she emphasised the importance of actually understanding what social care is.
“I think people still think it’s some sort of cream tea society when actually what we are doing is delivering health care functions,” Nadra noted.
“We’re looking after people at the end of life. We’re looking after people who would have been in long stay NHS facilities. That’s what we do. It is elements of health care that are in addition to the social care elements which we carry out so once somebody has had the acute care they need in a hospital setting, social care picks it up, so I think there needs to be an acknowledgement of what that means and that needs to be appropriately funded in the way the NHS is funded.”
The NCA head said it was “laughable” that it cost £2,100 to look after a person for a week in hospital while a care home would be expected to look after that same person for £550-650. She added she would like to see more about career pathways and how to make the sector more attractive in the reforms.
Additionally, Nadra said she would like to see providers being empowered to have enough interaction with local authorities and other decision makers, including CCGs, to create solutions.
“Providers need to be around many more tables than they are at the moment, both locally and nationally, so that we all learn from each other’s experiences and actually create sustainable partnerships going forward,” Nadra said.
“I think the time for this to be a fragmented type of service whereby things are done unto providers and decisions are made by local authorities and CCGs and then laterally discussed is over, and we need to get a grown-up view. This is about people’s lives and we all have a really big part to play in it so we should all be equal partners.”
Nadra said she was unconvinced by suggestions that health and social care should be more closely integrated.
“I think the way that social care has been treated thus far doesn’t give me any confidence that we would have a bigger part in an integrated model,” she noted.
Instead, the NCA head called for the creation of a Secretary of State to fight social care’s corner.
“We contribute £45bn to the economy, have more beds and employ more staff than the NHS, why shouldn’t we be recognised as an industry in our own right and why should we not be acknowledged as a sector?” Nadra asked.
“We need somebody to fight for social care and if we’re part of the NHS, I suspect we won’t get much of that. I am sure there are parts of social care that can be integrated but I don’t know how the model would work and I fear a fully integrated model would not give social care the status it needs and deserves.”
Asked whether the promised social care reforms would be as radical as hoped, Nadra told CHP she was an “eternal optimist”.
“If they’re done under a Government that tells us it is going to make significant change then we have to believe it but I will wait to see it happen,” Nadra said.
“I just hope it doesn’t keep being put back until it feels like nobody wants to tackle real reform. I hope it is reasonably radical when it finally appears but I also hope the government doesn’t throw the baby out with the bath water because there are some really excellent parts of social care that need to be retained.”