The scale of the crisis
Exhaustive data collection efforts by the International Long-Term Care Policy Network has allowed us to produce a per capita, international analysis of COVID-19’s impact on care homes. In lay terms, what this graph allows us to see is which countries’ care home populations have fared particularly badly compared to their non-care home populations (the group labelled “outside community” in our graph). In countries above the trendline, care home residents have suffered with extreme disproportion. Those below faced better odds.
But to be clear, in almost no national context is “proportional” a suitable term to describe the devastation SARS-CoV-2 has wreaked inside care homes. Across the 21 countries in this dataset (counting the UK as a single), less than 1% of the population has taken more than 43% of the bullets. Collectively, their care home casualties hit 300,000 around the start of this year, a population the size of Orlando, Florida.
So before taking comfort in the data, leaders should see patterns of failure. Most countries – including better-faring Finland, Germany and England – put care homes back-of-the-line for PPE allocation, causing fatal shortages. They also heavily restricted care sector testing, saving it for symptomatic cases: a shock followed in May when Belgium first introduced comprehensive care home testing, and 73% of confirmed cases were asymptomatic. And in a sign of either gross negligence or willful ignorance, most of these countries did not even count care home casualties in their early death tolls, preventing informed intervention.
What tipped the scales?
Comparing care home policies on the flipsides of this graph offers some valuable lessons. Wales – which has fared relatively badly at a community level – fares less dismally with its care home figures, in direct opposition to Scotland where almost 1 in 10 care home residents have died from COVID-19. Since each country uses the same UK-wide codes for recording COVID-19 data, comparing them is a good place to start.
Tellingly, Wales has only one fewer care home than Scotland does, despite having 12,000 fewer care home residents – this contained outbreaks by spreading people between more buildings. It also hints at how much each country values its care sector: when the pandemic broke out, Wales was the only UK nation to have seen real term spending increases in its care sector since austerity in 2010.
While Scotland has relatively high-capacity care homes, other countries have relatively high-capacity bedrooms. Only 8% of Spain’s care home residents have single-rooms, compared to 100% of Denmark’s (who fared much better). A review in Ontario estimated that if all care home rooms had been single-occupancy, nearly a third of their deaths could have been averted.
For-profit management of privatised care facilities have also come under harsh review. Canadian researchers found a 6·5% mortality rate in for-profit care homeless compared to 5·5% in non-profits. In Australia – where care homes accounted for 75% of all COVID-19 deaths (an unparalleled global statistic) – every facility is run for profit.
Policy aside, the deck is dealt to the distinct disadvantage of care homes already. They are populous settings with communal living spaces and unusually vulnerable populations— some more than others. Dementia has especially high COVID-19 mortality rates and causes atypical symptoms that confuse diagnoses. 61-76% of Spain’s care home residents have dementia, an unusually high proportion mirrored in the many who died from COVID-19.
But international coronavirus comparisons must be taken with a pinch of salt. Countries can neither decide how to define ‘care homes’ nor how to record figures. High-scoring Germany includes homeless shelters, asylum-seeker accommodation and prisons in its care home death toll – slicing the average age, and the death rate with it. Meanwhile, Portugal’s figures may only include deaths that actually happened inside care homes, as opposed to all residents’ deaths.
From the outset, it looks like we’ve learned our lesson. Care home residents are consistently listed in countries’ top vaccination priority groups. But prioritisation is not necessarily practice. England, Germany and the United States put health care professionals and older people in care homes behind those in the outside community, even though they face higher death rates. This is likely due to logistical issues with getting adequate cold storage for doses to care home workers and residents. There are also complications with consent, given a high proportion of care home residents may lack capacity due to dementia.
One thing is abundantly clear: prioritising care homes from the start would have axed the head off global death tolls. There should be no question about that in future policy. What we should be questioning, urgently and internally, is how we came to devalue our elder and more vulnerable community members with such fatal ends.