Who cares for care workers?

Published in Daily Maverick, 28 April 2020

On 25 April 2020, the UK government announced that the steeply climbing Covid-19 death toll had surpassed 20,000. The figure is shocking. Last month, the UK’s Chief Medical Officer, Sir Patrick Vallance, said keeping the UK’s final Covid-19 death toll below 20,000 would be ‘a good outcome’. However, the extra shocking news is that the real death toll to date is more likely to be 40,000.

On 22 April 2020, Financial Times journalists trawled through data provided by the Office for National Statistics and concluded that “the coronavirus pandemic has already caused as many as 41,000 deaths in the UK”. Every day, a senior government minister announces the number of deaths. But they only tell the tale of hospital deaths. Not the large numbers of elderly people dying in residential care homes. They will also not admit how the marginalisation and exploitation of care for the elderly has left old people and their carers the most exposed front to the ravages of Covid-19.

This point, however, was not lost on the UN Special Rapporteur on Human Rights and Extreme Poverty who last week laid responsibility for much of the disaster at the door of Boris Johnson’s austerity policies which, he says, have led to a “fatal weakening of the community’s capacity to cope and respond over the past 10 years”.

My own experience and witness over the last two months means I can only agree. It starts like this …

One month ago, the day before the UK went into lockdown, I had to move house suddenly. It’s a long story, but what made it extra tricky was Ollie, who, one hour before he was due to shift big bits of furniture, texted to say he wasn’t coming: “I can’t get anyone to risk their life for a tenner an hour.”

I explained I’d keep well out of his way, that two hours in and out of a storage room that hadn’t seen a human for several months was seriously low risk, but he wasn’t having any of it.

I was getting pretty desperate when, a few hours later, another furniture remover, Keith, replied to one of my panicky messages: “I’ll be right over, Just as soon as my Missus is home from work.”

I called Keith to check that he was okay with any potential risk and his clarity was alarming. He “wasn’t bothered, as a family they were just waiting to get it”. His wife was doing the best she could, but what options did she have? Hers was the reliable family income.

He told me how every morning she was at work, doing “personal care” for the elderly in a care home. The family were all worried, “she had no special clothing or equipment – but what could they do? She cared about her clients, they needed the money,” and Keith (correctly) predicted that this would be his last day of work for months. 

18,516 people died in the weeks leading up to Easter – an “unprecedented level of deaths” in England and Wales, says the Office for National Statistics. The number of deaths in the week to 10 April 2020 were the highest weekly death rate – from all causes – since statistics started to be gathered, and twice as many deaths as is usual at this time of year. To make it worse, it’s definitely an under-estimate – most registrars close on Good Friday, so this reflects the number of deaths reported over six (rather than seven) days. The massive leap in deaths – to about 3,000 a day – is of course due to Covid-19.

But there are twists to that story.

The UK’s steeply climbing Covid-19 death toll has recently surpassed 20,000. But it only tells the tale of hospital deaths. In part, it’s because hospitals are the place where patients get tested, but a test result is not essential for a doctor to report “suspected Covid-19” as a cause of death. Many people think the government is deliberately trying to keep the numbers low. Scotland reports on all Covid-19-related deaths and explains, quite openly, that 25% of their 985 Covid-19 deaths were in care homes (almost half of which have reported Covid-19 cases).

Those Easter figures report on all deaths in England and Wales, and when you dig below the surface, the biggest leap is a doubling in deaths reported by residential care homes. They reported nearly 5,000 deaths in the week to 10 April (4,927), compared to 2,471 a week just one month ago. Inevitably, people die in care homes (they’re mostly full of elderly people), but why the sudden doubling?

One of the confusing factors with these statistics is that less than 20% (16.8%) of these deaths are officially registered as being “Covid-19-related”.

So what accounts for the sharp increase of death in care?

It could be that elderly residents with Covid-19 symptoms are shipped off to hospital to die there. This seems unlikely. The past few weeks have been full of reports of GP surgeries asking care home managers to sign blanket “Do Not Resuscitate” forms for all their residents.

Another explanation is that many residents have become “collateral damage” – too frightened to go to hospital when other illnesses emerge, and since GPs and nurses will no longer visit care homes (it’s too risky for them), how can they judge the severity of their conditions?

A masked man walks across the London Bridge in London, Britain, 23 March 2020. EPA-EFE/ANDY RAIN

Medical staff are on tap to do telephone consultations, but they rely on the elderly and their care workers to pass on reliable information. And when people die in care homes, the doctor has a chat by phone with the care worker, who then fills in the death certificate (there are some reports that family members will soon get that job).

In the absence of a test, doctors can use their clinical judgment, but it’s hard to decide to put Covid-19 on a death certificate when the doctor can’t see her patient (the NHS has been very slow in rolling out consultations by Skype and the like), and is relying on reports from someone who probably left formal schooling at the age of 16.

Until a few days ago, the policy was that if five people in a care home had tested positive for Covid-19 – for example, when she was in hospital – then the managers were told to assume that everyone who died (or had related symptoms) had Covid-19; they know it moves like wildfire.

Cruise ships rang the Western alarm on this epidemic when Covid-19 moved at dramatic speed through those – very different – forms of high-density accommodation for the elderly. It is blazingly obvious that Covid-19 will be an extreme risk in any institution where vulnerable adults – many with dementia and other cognitive challenges – live in close proximity to each other, and rely on poorly paid staff who care for their basic personal needs, toileting, feeding and the rest.

Some of the UK’s high-density accommodation for the elderly have specialist nurses on their staff; care homes don’t. These are the places that rely on an undervalued, underpaid – and allegedly “unskilled” – horde of women and men to do the tasks that many of us are happy to farm out. Which is why leaders of residential care homes have been banging the drum for weeks, calling for a “Ring of Steel” to protect their residents and their workforce. They want the PPE (Personal Protective Equipment) and access to testing to make their work safe for staff and residents – it hasn’t happened yet.

The UK has an aging population (some 12 million people are over 65), but the government doesn’t track how many of them live in care homes, which exist within one of those devolved, fractured public-private networks that have become a recent hallmark of British society. A commercial report (from 2017) suggests that there are some 400,000 people living in over 11,000 care homes – operated by 5,500 not-for-profit and commercial providers that charge their residents or local authorities about £44,000 (approx R840,000) a year for this type of care.

The annual wage for full-time workers in those care homes is less than half that (and many of them work part-time), with salaries bumping along, tracking the minimum wage of £8.72 (approximately R160) an hour, or £4.55 if you can get someone under 18 to do the work – and many can, or used to. According to the UK’s Secretary of State for Health and Social Care, Matt Hancock, currently the UK has 1.5 million care workers working for those paltry wages (one hour of this under-appreciated work might just buy you a very cheap bottle of South African wine over here).

A hand out photograph made available by n 10 Downing street shows Britain’s Health Secretary, Matt Hancock holding a digital Covid-19 press conference in n10 Downing street in London, Britain 23 April 2020. EPA-EFE/PIPPA FOWLES / DOWNING STREET /

I heard a care worker weeping on the radio yesterday. 

She runs a small team in Hampshire, a beautiful rural part of Southern England, identified at the start of the epidemic as having especially high prevalence. Her workers look after elderly people in their own homes and they are desperate. A couple of weeks ago, her team looked after 45 clients; now there are 35. They know that one of the people they cared for died of Covid-19 because she was taken to hospital to die. The rest were at home or in a care home so they didn’t get tested.

And she wasn’t just weeping for her clients who had died. Caring for the elderly, she’s used to death, although the speed of it astonished her. She was also weeping for her workers. A third of her staff are off sick, self-isolating or have resigned – but most need the work; many are single parents. And they’ve looked after many of these elderly people for years – they don’t want to abandon them now.

For weeks, she has been trying to get masks and effective PPE for her staff and she just can’t. Her team is working with little plastic aprons and rubber gloves; no masks. They are so frightened.

Sue Cawthray, the head of Harrogate Neighbours, a group that looks after hundreds of elderly people, described the situation as: “The time bomb waiting to explode.” Her team is scrounging PPE, getting donations from hair salons and other local businesses; there is no other supply available to them.

The UK Association of Directors of Adult Social Services (ADASS) wrote a (well-leaked) letter to government officials complaining about the handling of PPE for care staff, describing it as “shambolic, paltry and haphazard”.

ADASS also raised concerns that the “testing for care workers appears to be being rolled out without being given thought to who is going to be tested and what we are going to do with the result”.

The day before, Matt Hancock announced that the 1.5 million care workers would now be in the priority queue (just behind NHS staff), to get tested for Covid-19. He also unveiled a fancy new Green Badge for working in care – in part to help them get in the priority queues at supermarkets.

He’d already set a goal (for end April 2020) of getting 100,000 people tested daily, but currently the daily test rate is under 20,000 per day, and less than a quarter of care workers have been tested. Despite daily announcements of new approaches: book on-line – let the army deliver swabs to you, the numbers remain stubbornly low.

The UK has been using nine drive-through testing sites to limit contact. Care workers in Oxford – where the UK government is pouring money into one of two British Covid-19 vaccine trials – are not allowed to get tested locally. They were told to go to Twickenham: A 90-minute drive to the outskirts of London. They are not allowed to use public transport. Not so many poorly paid care workers have access to their own vehicles – let alone the 4-hour round trip to go and get tested, as well as to do their work and care for their families.

A few days ago, I checked in again with Keith: his wife is now caring for people in private homes – she reckons there is less risk there. She hasn’t picked up her shiny new green badge that reads “CARE” yet – they are out of stock. There was some talk of NHS and care workers getting a small extra daily allowance – benchmarked to what the army gets when they are on active duty. No one seems to have followed through on that. What she would really like is to get tested, to get her family tested and to get her clients tested. And to have the PPE she needs to do the heavy labour of caring safely and well, for her loved ones at home and at work.