Understandably and correctly, the last few weeks have seen a significant focus on the challenges our care homes need support with whilst tackling the COVID-19 pandemic.

What has continued to be under-recognised publicly, however, are the challenges that our equally crucial homecare services are facing in supporting individuals in their own homes.

On Wednesday 15 April, the First Minister provided the first set of weekly figures from National Records of Scotland.  These showed that 129 people with confirmed or presumed Covid-19 died at home or in their communities – over 13% of the total deaths in Scotland up to 12 April. In the same way as individuals who die in our hospitals and care homes, we must not forget that these deaths at home represent individuals.  Given that the virus disproportionately impacts the mortality of elderly and frail individuals and those living with other health conditions, it is not unreasonable to assume that a significant proportion of the 129, and indeed those in hospitals, had been receiving support at home through homecare organisations.  More people are supported at home any day of the week than in hospitals and care homes combined.

We must therefore carefully consider what support these organisations require in order to continue to provide essential care and support and therefore preventing additional demand on health services, as well as how their workforce is protected.

The critical challenges facing homecare during the COVID-19 pandemic include:

Access to PPE

Whilst we welcome the move to deliver a direct supply of PPE to care homes this week, we are acutely aware of the ongoing challenges for homecare organisations in accessing PPE supplies.  We want to see a similar move to direct delivery of PPE to homecare providers and access to supplies beyond those required in emergencies for suspected or confirmed COVID-19 cases.  Homecare workers must be able to access the appropriate PPE in sufficient numbers to meet current PPE guidance.  It must be recognised in supply allocations that homecare staff support many individuals across the course of their shift, often visiting the same people on multiple occasions, which leads to an increased need to change PPE more regularly.  There is also an issue of equity here.  There is one Guidance document covering all community care provision yet homecare members are telling us that their staff are supporting individuals in their own homes alongside other colleagues who are wearing significantly different PPE.  This leaves staff feeling unfairly exposed.  We are also aware of some Health & Social Care Partnerships where PPE is being provided for in-house staff but not made available for organisations delivering care on behalf of the Partnership. 

Organisational sustainability

These issues are also compounded by the fact that, as for other providers, homecare organisations are struggling to obtain PPE through usual supply routes and available PPE is significantly more expensive.  So far, there has been no explanation of the commitment for reimbursement or financial support offered nationally or locally for costs associated with Covid-related PPE. This uncertainty is impacting the already minimal margins for homecare organisations.  Providers have been asked to submit data on additional spend as a result of Covid-19, but with no guarantee or details of back-payment. This is creating issues of cash flow, particularly in additional staffing costs relating to furlough and uplifted sick pay, as well as for PPE. Many providers await clarity on the Scottish Living Wage uplift to enable them to pass that funding on to staff. Whilst clarification of the rate has come directly from Scottish Government, providers await local rates and start dates from local HSCPs.

Whilst Scottish Care is currently seeking to collect additional data in this regard, several homecare members have informed us that they have seen a 10-15% drop in care hours they deliver.  One describes having 126 vacant hours for this week.  These figures are unheard of when demand for homecare usually significantly outstrips supply. This is as a result of cancelled visits both by Partnerships and individuals who fund their own care, often because family members are not currently working or are working from home and are therefore able to step in to provide care.  Additionally, social work assessments are not being carried out as planned therefore delaying or limiting the provision of new or additional support to individuals who require it. 

Not only does this place organisations in an extremely precarious position, in a sector where sustainability can balance on a knife edge of care hours at the best of times because of the commissioning and procurement climate, but it risks the jobs and financial sustainability of thousands of vital care workers where they are willing but unable to undertake their usual hours.

Almost 2 weeks ago, COSLA released updated Guidance for Commissioners of social care in an effort to outline supportive measures. That guidance has fallen short, underestimating the requirement for clear national direction in times of crisis on what standards of good practice would look like, it provides a more ambiguous picture by adopting uncertain language such as ‘could’ ‘perhaps’ and ‘may’.

Contract flexibility

Whilst some Health and Social Care Partnerships are working collaboratively with homecare providers to provide flexibility in managing the unprecedented impact of COVID-19, others are continuing with ‘business as usual’ approaches to contracting, monitoring and funding. 

Some areas are continuing to operate minute-by-minute billing for commissioned homecare visits through electronic call monitoring systems, with no tolerances allowed for late or extended visits.  This results in financial penalties for the homecare provider.  This rigid approach does not take into account the need for flexibility in supporting individuals who may have lost their wider support networks due to current restrictions and therefore need additional time for support, or for staff to ensure the safety, health and wellbeing of an individual thoroughly including monitoring for COVID-19 symptoms.  It also fails to recognise the additional time required to operate stricter hygiene and infection control protocols, or to put on and remove PPE. 

At a time when we truly are all in this together, there must be trust, flexibility and partnership in health and care provision in order that the whole system and workforce can operate safely and effectively. 

Testing

We welcome recent announcements regarding enhanced testing access for health and social care staff and for care home residents.  This must specifically include homecare staff and supported individuals too. Homecare staff are experiencing high levels of anxiety and distress associated with fears of carrying Coronavirus unknowingly between the homes of the vulnerable people they support.  Testing can support these fears to be at least partially reduced as well as to ensure critical workers are off work for shorter periods of time when they or a family member are suspected of having Coronavirus but testing proves they do not.  There must also be routes to accessing testing which do not require significant travel, which is proving to be a barrier for homecare workers who do not drive.

Individuals supported at home may not see anyone else in a day, particularly at the current time.  Knowing if they have Coronavirus can therefore help to direct their care accordingly.  The homecare they receive, from individuals they know and have built relationships with who can spot early signs of health deterioration, is absolutely essential to their health and wellbeing.

Karen Hedge

National Director

Care homes have continued since the Coronavirus outbreak to both receive back individual residents from acute settings and to continue to have admissions from both the community and hospital  settings. This is a critical role for care homes and is in part to make sure that there is no greater pressure on the acute sector than it needs to be. But it should be understood that care homes always have admissions from hospitals. If care homes stop doing this then individuals will be stuck in hospital which would effectively put them at a much greater risk. Staying in hospital longer than you need to is something which we know carries real danger for patients. It is also something which can be immensely distressing for individuals who might be living with dementia.

The difference with COVID-19  is how these admissions are handled. When being discharged from hospital it is often routine for the person to be tested if they have been Covid positive to make sure they no longer have the disease. However, testing will only show whether the person has Covid on that day. It will not show if they had it before or if they will get it. There are also dangers from  false-negative tests. What there is are strict clinical assessment protocols which are in place before discharge.

Once someone arrives at the care home they will be isolated and will be barrier nursed as if they have Covid – even if it is recognised they do not – this is a belt and braces approach and lasts for between 7-14 days dependent on the risk assessment of the individual. We have made it very clear that no care home should receive any new admission or returning resident unless staff are clear that they have sufficient PPE to allow this to happen. Some care homes have isolated individuals in separate units with separate nursing teams to reduce the risk of cross-infection.

I would ask those who do not want admissions to happen and returns to happen what they would do with these individuals. They are not objects or commodities, they are human beings, often frightened in an alien environment and wanting either to go home or to get some stability. What would you say to someone who is simply trying to get back to their own home including those who have come through the battle with Covid?  Hospital can be a confusing and distressing place for someone with dementia – they want back to what is familiar and safe. And I would ask what would you say to someone stuck in hospital, often with conditions other than Covid, in the knowledge that they are at greater risk of infection and deterioration the longer they stay there?

We need the least restrictive and safest option for the most vulnerable.

Some of the commentary over the last weekend has been inaccurate, alarmist and insensitive. In all the emotion of the moment, we all of us need to remain respectful, to use language which affirms individual worth, and always to seek the best interests of the most vulnerable.

 

Dr Donald Macaskill, CEO