By: Dr Owain WilliamsFor those after a short read, please look away now.
In this second part of my post about COVID, aged care and neoliberalism (see May 5 for part one) I want to give focus to the consequences of marketisation in the COVID crisis. Having so far detailed the withdrawal and reformulation of government from a privatized and increasingly financialised long-term aged care sector, and detailing the precarity of residents and of a highly gendered and poorly paid staff, it is now time to deal with the consequences of a system set up for failure. Even the best prepared and funded long term aged care systems have felt impact of the pandemic for sure, but in those where neoliberalism has been most apparent the outcomes have been so far much worse.
The aged care system in many nations has proven very fragile and unable to cope with the crisis, and the market and the governments that finance and regulate that private sector have also failed in a duty of care to a vulnerable population, and spectacularly so. One of the most awful features of the scandal that has emerged in the UK, Italy, Spain, Canada and US, and now so it appears in Sweden too, is that it has proven politically and economically convenient to tolerate deaths in care facilities. Having deaths take place in aged care has eased health systems capacity issues, especially in the UK, and have allowed beleaguered governments to present apparently flattening curves to worried or hostile publics. However, the scale of deaths from COVID in care homes across Europe and North America are only recently beginning to be appreciated in recent weeks, as the numbers of deaths counted as COVID-related have been effectively buried in a number of countries by poor and incorrect recording of the cause of death of residents. Statistics have caught up or caught on, and the scale of what has occurred is genuinely shocking.
According to WHO-Europe, it is now thought that in most of the high prevalence countries in Europe around 40-57% of mortality from COVID has occurred in aged care facilities. Of the 24,895 deaths in France as of the April 9, over 9,000 of deaths occurred in long-term care. Much the same figures, if not worse are true in North America; in the Atlantic Canada region aged care mortality accounts for 78% of all mortality from COVID.
The BBC recently carried a story on the situation in Spain (Inside the story of Spain’s care home tragedy), where the worst impacts of COVID in aged care first dramatically appeared on the world news channels. There are over 5000 care homes in Spain with three quarters of these privately run. At the time of reporting, there were 16,000 care home deaths in Spain, and from 8th March to April 9th there were 4,260 deaths in the Madrid region alone. In Italy, estimates are that over half the deaths have been in aged care; in France 45%; Ireland 54%; and Spain 57% (LSE Long-term Care Policy Network). In Sweden today it is 50%, all in the context of a hotly debated epidemic response in that country in which aged care fatalities seems to have been tolerated or absent from the strategic thinking.
Until the last week of April, care home deaths were not being reported in the UK’s COVID tally, and the UK Deputy Chief Scientist recently announced that the country ‘needed to get a grip’ on the true numbers. As Grant Schapps the government minister blithely states that numbers are falling at the start of this week, care home mangers collectively point to anticipating 5,000 deaths in the next two weeks to mid-May. On the 3rd of May, the spread and scale were becoming entirely evident in the UK. For example, a care home in Portree on the Isle of Sky announced on Monday that 28 of its 34 residents had tested positive, as had 26 of the 52 staff. On the same day, Monday 4th, a care home in Pinner, North London, reports 3 deaths in one night, 20 residents now infected. With 80% of the staff now self-isolating the management beg for help. The Observer on 3rd May reports that in just the two weeks to that date that over 4,000 care home deaths from COVID had been reported in Wales and England, cases now outpacing those occurring in hospitals, and set to spiral further upwards according to multiple care home sources and service providers.
Much the same is happening in the US and Canada, the care home environment and co-morbidities and existing conditions of the residents interacting to produce a cascade of grim outbreaks in both countries. The New York Times reports on April 17th that 36,500 residents had tested positive nationally. This testing of residents was probably only occurring in the more high-end facilities with better resources, and for some the testing of the elderly seems to have continued despite being de-prioritised by the government in the wider long term care sector. Things have not changed in that regard, but the numbers of those infected or dying have certainly ratcheted upwards in the last three weeks, and will certainly get much worse in coming weeks and months. In New York we already know that there have been 4,800 care home deaths. In New Jersey the head of the state industry association asked that the National Guard be deployed to homes, such was the scale of the disaster.
Then there are the very visible signs of market failure in private sector aged care. The abandoned care homes with sick or dead residents left in their beds. This story emerged in Spain in late March, gripping the world as soldiers were sent in to disinfect 1300 care homes. From the New York Times on the 25th March:
‘Soldiers who were sent to disinfect nursing homes had found people “completely abandoned, or even dead, in their beds,” the defense secretary, Margarita Robles, revealed on Monday. More gruesome discoveries followed, including the revelation of two dozen deaths in a single nursing home in Madrid. Amid the thousands of tragedies created by the virus, the stories emerging from those homes have shaken the nation not only for their horror, but for undermining the view the Spanish had of themselves. Spain’s government has not said how many bodies or neglected residents have been found in nursing homes, but Spanish public prosecutors are investigating possible criminal neglect.’
What initially was seen very much as a unique and perhaps racially constructed story of tragic Spanish failure and national guilt, started to appear elsewhere. Canada, the paragon of liberal social welfare and caring tolerance, began to see instances of abandoned homes in Ontario and Quebec. This from the Globe and Mail, April, 12th, from Montreal, Quebec:
‘Résidence Herron, Montreal PQ, The Quebec coroner, health authorities and the police have launched investigations in the wake [of the discovery]. They found dehydrated residents lying listless in bed, unfed for days, with excrement seeping out of their diapers. “I’d never seen anything like it in my 32-year nursing career,” said Loredana Mule, a nurse on the team. “It was horrific — there wasn’t enough food to feed people, the stench could’ve killed a horse.” After she left the home, she said, she collapsed in her car and wept. A skeleton staff of two nurses had been left to care for a private residence with nearly 150 beds, she said. The remaining staff had fled amid the outbreak of the coronavirus, leaving patients, some paralysed or with other chronic illnesses, to fend for themselves. Relatives described a facility where only one or two orderlies remained on each floor, urine bags were left dripping on floors, residents struck by COVID-19 were not properly isolated and others lacked food or clean drinking water. In announcing the deaths on Saturday, the premier of Quebec, said there appeared to be “gross negligence.”
In Italy from the BBC, March 31:
In Italy, hundreds of deaths have been reported in residential homes in Bergamo in the north, while 83 elderly residents went without food at a home for two days in the south because staff had to go into quarantine.’
Cases of partial abandonment (rather than the clearly horrific total absence of staff) in the face of the pandemic are now numerous; homes left with skeleton staffs, the others too fearful or ill. However, we must remember that this sector was chronically under-staffed before the crisis. One recent Harvard study found that some three quarters of US homes were lacking sufficient staff numbers before COVID even transpired. Lawsuits and criminal negligence claims multiply and regulation and assimilation of the private sector into the health systems of countries has proven inadequate.
So what can be drawn from this reportage and what can be added to what is already known?
Let us start with the staff and care workers. At the end of the day it is difficult to ascribe much or any of the blame to those who are poorly paid and marginalised in the care economy for what has unfolded in the last months. In the main, the problem in all the countries is ultimately systemic and with what has transpired in the aged care sector by means of neoliberalism, privatisation and the reformulated role of states and local authorities. Staff failing to turn up for work are just the expression of these drivers and are not be blamed. We must remember that many of the staff are not only poorly paid but are on tenuous or zero hours contracts. Rotating through a number of residencies or means of service delivery have become normalised, and this has seriously challenged infection control for entire facilities. It has exposed these staff to more residents and more of the virus.
Likewise, staff who are themselves ill, or feel that they might have been exposed, would naturally either not attend work, or, far worse, continue to attend because of a lack of sick pay or dependence on meagre incomes. Both these factors have been at play, with huge shortages of personnel in most of the semi-deserted facilities testifying to the fact that some carers put isolation before income. These are not abstracted musings but can be evidenced by multiple examples of continued transmission or isolation by care home staff in man of countries in recent months.
Fear would certainly have played a role in those staff staying away from their charges for reasons of self-preservation, that coupled with the obvious disincentive of poor pay. In Spain, those that abandoned their sick and dead patients were likely fearful of the risk of infection, and very likely not trained to deal with an infected patient, alive or dead. In France, care home staff absenteeism in the crisis is now being reported at some 40%, with many sick or simply not turning up. In New Jersey some one third of care home staff themselves contracted COVID. There was no spare capacity in the system to deal with a crisis, and much of that system stood outside the mainstream health sector as a self-contained area of care and as a distinct political economy. This devolution aged care by privatisation has also failed.
Added to fear, we have multiple uncertainties at play. It has been persistently obvious for at least two months that many staff could not know their status, nor that of their residents, simply because testing was not available. In many countries care homes were not prioritised for testing where it was available at all. This particular crisis of testing still plagues the UK and US. Earlier this week many outlets reported from a Royal College of nursing survey of some 22,000 hospital and aged care workers staff:
‘The Royal College of Nursing (RCN) UK-wide survey of more than 22,000 health and care workers was conducted over the weekend before the government’s announcement of testing expansion. RCN survey of NHS staff and care workers – some 22,000 in the survey: At that time, 76% of all those surveyed said they had not been offered a test. Of those, 44% said they did not know how to access testing. The RCN also found more than four in five temporary staff had not been offered Covid-19 testing, compared to three-quarters of permanent staff. The survey found 79% of those working outside of the NHS had not been offered a test, compared with 75% in the health service. It found that in care homes and prisons, about 50% did not know how to access tests. With temporary staff, this figure was 60%.’
In the depths of the crisis the state continued to fail a system it had invested so much public money and faith in. We must also consider that as early as mid- March the line between care workers being required to provide medical assistance as opposed to basic support and assistance for residents had been effectively crossed. Most care homes in the OECD have become de facto medical facilities as the virus has entered them. This was inevitable in a pandemic, and medical care and supervision has always been present in care facilities anyway for those needing more constant support and clinical intervention. Yet COVID has highlighted how far the balance has shifted to poorly paid and often minimally trained staff in many facilities.
Here yet another driver of failure kicks in, with downgrades and eroded medical training and personnel to be replaced by substitutable (a rotated) low wage replacements, and clearly weak regulation of the quantity and availability of trained medical baseline presence at facilities, all combining to produce a catastrophe of the market meeting aged care in a crisis. This disaster has not struck in Denmark, Norway, Finland or Switzerland, precisely because they have not gone that road.
All this is somewhat balanced by stories of kindness and duties beyond the contractual being offered to elderly residents. We hear of staff around the world electing to isolate with their charges, away from families, or continuing to attend those they felt responsible for until they became too sick to continue, or themselves died. The marginalised staff have acted with altruism in many cases while their governments have not.
As the virus spread in care homes other market failures have interacted to multiply the severity of the impacts in care. There are now numerous examples of long-term care facilities having no access to oxygen in the UK and USA , nor the ability to isolate sick residents from those infected. Similar shortages of oxygen were present in France and Spain. Staff shortage is endemic to the sector in almost all OECD countries, and this situation has worsened as carers became ill. Those that remained have been swamped, and surely only have been able to give very basic care as conditions became more acute and cases escalated. The acute shortage of PPE in aged care facilities has been a persistent issue for staff, and what has plagued hospitals in many countries is represented as more a severe failure in care homes. Staff have not been able to protect either themselves or their charges by this basic means of medical prophylaxis, with Lewis Goodall on Newsnight confirming this week the scale of that scandal. Staff in the UK have been making their own masks, or had to buy them when and where they could out of their own pockets.
Amidst these events the regulatory state has shown itself prepared to continue to support the private sector through the crisis. This is perhaps sensible for the present. Indeed, much of the sector was often already financially precarious, much because of the profits extracted from it by financialization, debt and shareholder dividends, and the crisis has made this worse. States are injecting money to keep providers afloat. This is not a new arrangement, and pre-dates COVID; with countries such as Australia routinely injecting money into the private care sector (and the public and charity sectors it must be said) to stave off financial collapse.
However, the COVID measures reflect not only the response to much predicted imminent financial collapse of care forms across the world, but also government’s belatedly plugging gaps in the sector that privatisation and weak regulation has created. In the UK, for example, NHS England committed to special funding of GP practices to provide attendance at care homes. In Ontario, Canada, the state has created a special $243 million fund to ensure staff and resources are present, while drafting in state employed nurses, dietitians, and physiotherapists, all to provide specialist resources and support. Australia announces a $100 million package to upgrade and train care home personnel, $235 million for worker retention, and a further $78 million for ‘continuity of workforce supply’. This is to be welcomed, finally a subsidy to a sector and neglected workforce, but they are nonetheless late and reactive measures to a systemic crisis of care that government has itself facilitated. On top of this, direct government bailouts and special emergency funds multiply, in the UK, Australia, Canada, and the US. The industry is calling for billions in bailout money to meet COVID, with the industry association in the USA asking for $15.5 billion for short-term measures to meet COVID. In the UK, firms are also transferring the additional costs of dealing with COVID to their patients. We hear reports of a Dorset based multi-site provider attaching a further £200 per month to bills to provide PPE.
As neglect and failure have become apparent a blame game has emerged. Whereas the reaction of the Spanish and Canadian governments has been to institute legal proceedings against negligent firms, in the US some states have granted blanket legal indemnity for the care sector, protecting providers from private and public suits. Florida, a state that supports a huge retiree and assisted care economy, is one case in point. Added to this, routine public enquiries will be instituted in many countries. Australia, for example, have a long track record in enquiries into various failings in aged care. Hopefully, these enquiries will go somewhere and lead to lasting and systemic change, but this would be a radical departure from the past.
But the private sector companies are blame shifting already, especially to government and local authorities. This blame game is now playing out very visibly in the UK, with The Telegraph running articles in which private care associations and facility managers are accusing local authorities of hoarding funds. This is at the precise moment where Matt Hancock, the UK Minster for Health, is turning to private sector providers to manage a range of COVID-related services. In crisis there is opportunity for further privatisation and extraction of government money. It could be that private aged care might be further embedded and supported by future government policy and funding.
I feel reasons for deep pessimism for the much needed reform, albeit balanced by opportunities that are present.
First of all, we are presently prisoners of 3 or four decades of privatisation in the long term aged care sector, and there is no alternative to it at this juncture. We therefore have no choice to support and maintain what we have in place, at least in the short term. The private provision of care is the default system, and we should expect for governments in the OECD to be continue path dependent, perhaps for much longer as COVID eventually recedes. Yet we have at least an opportunity to better regulate that sector and ensure adequate standards of training and care. The balance between care assistants and trained staff must be urgently addressed, as should wages and contracts. We need more than the illusion of the regulatory state. If care homes and multi-site providers cannot meet these new standards or are further financial broken by them, then states and local authorities should take over the homes and services, and given the turmoil and turnover in the sector in recent decades, they should in fact plan for that eventuality.
Second, governments have proven themselves very complicit and implicit in the system of care that has developed around the entrance of the market. Governments in all shades of the blur political spectrum under neoliberalism have committed to the same basic game plan. They have clearly felt themselves the beneficiaries of passing aged care to the market, and have willingly believed that the process of transferring costs to patients and families is a cost saving for all in society by means of the invisible hand. If they did not believe at least this then they are simply callous as well as negligent. Under COVID, the cost savings have exposed that the invisible hand degrades staff, the standards of care, and patients. The government needs to be more than the regulator and occasional lender of the last resort in this vital system.
What public monies are directed into the private sectors in the future, and this is already substantial in many countries, should be made in the form of much stricter conditionalities in terms of what can be extracted in the form of profits. Financialization and hedge fund investment is clearly a case of commodification of the vulnerable and elderly, and is clearly a bridge too far even in these neoliberal times.
Yet, finally, care homes have provided a convenient political escape route and a health systems pressure valve in the last few months of COVID. Not only have governments in the UK and USA, in France, Canada, and Spain, been passive or active in letting people die in long term care, many countries and authorities actively discharged elderly patients in hospitals into long term care facilities. In Italy, Spain and the USA, there are multiple instances, if not systemic policies, where sick care home patients were being turned away from hospitals. Politically, it seems that those deaths were politically convenient if they just disappeared, to became silent causalities of the normal attrition of our elderly in care. Fortunately, statistics have now caught up with this strategy of omission or commission. If not a deliberate act, it was one of the utmost callous neglect.
We badly need change in this area of human life and social organisation. It is perhaps corny to state it like this, but the scale of each individual death could perhaps point to way to a new system of socialised aged care based on values that are not of the government supported market, the too cosy relationship which has so clearly failed our elderly populations.