Pandemic has forced us to think hard about how we care for elderly
As a society, we have failed to address many weak elements in our healthcare system, writes Mark Roe
IT is just over four months since the first case of Covid-19 was confirmed in the Republic. Since then, over 25,000 people have tested positive and 1,741 people have lost their lives. As we get to grips with the ‘new normal’, we’re discovering the need to change how we do things. Few changes are more relevant than how we might prepare for inevitable public health emergencies from now on. A good way to start is to address how SARS-CoV2 got to the people who had the worst outcomes.
At least 50pc of coronavirus cases in Ireland arose from healthcare settings such as hospitals and residential institutions: 32pc from healthcare workers and 20pc from nursing home residents. What tells a unique tale is that despite accounting for 20pc of all cases, so far nursing home residents account for only 11pc of hospitalisations but 66pc of all deaths.
Over the last four months much has been spoken about protecting vulnerable people and cocooning the elderly. The need to shield the most susceptible in society became evident as the daily reporting of deaths was accompanied by the phrase “underlying conditions”. As 93pc of people who died with Covid-19 were aged over 65, we shouldn’t be too surprised that 91pc had an underlying condition. Each year in Ireland we have over 17 million GP visits, 14 million hours of home help care, and 73 million prescribed medications dispensed. Only one in three achieves the recommended amount of physical activity and six in 10 are overweight or obese.
These facts about the health of the nation were known long before Covid-19 emerged. So who really are the vulnerable?
The death rate in nursing homes is 308 times greater than in the general population. Hiqa, the Health Information and Quality Authority, maintains a public register of residential care facilities for older people; 25pc of facilities on this list reported a Covid-19 death. Focusing on facilities that had 10 or more deaths produces some stark statistics. These 36 facilities, 6pc of those on the Hiqa register, account for 66pc of all deaths in nursing homes and 33pc of all deaths in Ireland.
We knew from Wuhan, Italy and Spain that the frail elderly were taking the brunt of this pandemic. We advised the over-70s to cocoon but did we initially neglect those frail elderly who couldn’t social distance as they had to be cared for? If so, what is the value of modelling how many people might be transmitting a disease if we ignore the simple fact that a small section of society has the majority of cases?
By reporting that 40pc of cases are transmitted in the community, we lose sight of where the problem is really running riot. Half of all cases are hospital or care home workers and nursing home residents. This suggests it is unlikely that 40pc truly contracted their infection in the community as close contacts of other confirmed cases, including hospital and care home workers, need to be considered.
So far in Ireland, Covid-19 appears to have largely been a hospital- and care home-acquired infection. Before Covid emerged, 4-6pc of people in hospitals or long-term residential care facilities had a healthcare-acquired infection at any time. When a completely new infection appears, healthcare workers urgently ready their systems to respond. Any delay, or overlooked step, gives the infection a chance to spread by exploiting faults in the system. One such fault is the capacity to reduce opportunities for infections to spread in nursing homes. When Hiqa assessed infection controls in nursing homes on 215 occasions in 2018 they found regulatory non-compliance in 18pc of cases. A similar rate of breaches in staffing and training requirements were found.
When these factors are known to exist, it can be nothing short of disastrous to discharge a nursing home resident from hospital into such an environment if they are known, or suspected to be carrying Covid-19. The likely outcome was obvious as it was inevitable that some facilities would face difficulties in keeping other residents and staff safe.
Since 2001, Migrant Rights Centre Ireland has raised concerns about working conditions and pay for the care workers that so many people in our society depend on — migrants are over-represented in this sector. As many care home workers live together, and regularly must work in multiple facilities and care homes to earn an income, it was also inevitable that Covid-19 would move not just from person-to-person but from facility-to-facility.
As a society, we have failed to address many weak elements in our healthcare system. We have failed to cater for the simple fact that no part of any system operates in a vacuum; every part must be connected from end-to-end so that informed decisions can be made. It should have been possible to both prepare the acute sector for a possible surge and also shield the most vulnerable in care homes. Visitors were banned from nursing homes since early March so the only way the virus could enter was from patients discharged from hospital and via infected staff.
If the Covid-19 pandemic has taught us anything, it’s that we need transparent collecting and reporting of data to inform public health decisions. The information we needed to identify who the vulnerable really were was available to us; it just wasn’t in one place. This makes it hard to identify where to act next, what that action should look like, and, ultimately, whether that action is making a difference.
We didn’t need a pandemic to realise that our healthcare system provides excellent conditions for making a bad problem worse. But maybe we did need a pandemic to ensure that the system we all want finally emerges. As a society, we must make our priorities known and see that they are acted upon.
As we’re discovering the many changes in our society, there has never been a better time to reimagine what caring for the most vulnerable people in the most vulnerable places looks like. We should start with caring for the ageing. Our need for home help and residential care facilities is expected to be 54pc greater by 2030. These are the factors we need to start caring about.
The current model of how we care for the elderly is outdated. The people who died in nursing homes over the last four months deserved better from us. At this moment, up to 32,000 people are in nursing homes around Ireland — they deserve better, too.
‘We should start with caring for the ageing in our society’