VIRUS: THE CARE HOMES DEBATE FROM HOLYROOD

By Bill Heaney

Have people been moved from hospitals into care homes without knowing whether they had Covid-19 or whether the virus was in the care home?

This question from Tory Graham Simpson sparked a major debate in the Scottish Parliament on Tuesday.

Since West Dunbartonshire has been so badly affected by pandemic, The Democrat has decided, because our digital platform is not constrained by space as newspapers are, to give a full airing to this important debate.

What follows is from the official report of the Scottish Parliament:

  • Jeane Freeman: 

    I cannot give the member a definitive answer to that question. I can give an answer with respect to the date from which we required the two negative tests before someone could leave hospital to go to a care home if they were a Covid patient and the single negative test if they were not, and the requirement on community admissions. I will give Mr Simpson details of that after this statement. However, I cannot give him an answer on the situation prior to that.

    With your indulgence, Presiding Officer, I will restate the point about why those tests are not always undertaken before the individual moves to the care home. The main reason for that is the clinical view on the balance of risk: that the risk in staying in the hospital is greater than that of moving to the care home, and that the move to the care home can be mitigated while waiting for the test results by the requirement for 14 days of isolation.

  • Neil Findlay (Lothian) (Lab): 

    Why does the cabinet secretary applaud care home workers on Thursday evenings, only to instruct MSPs on the COVID-19 Committee today to vote against amendments that would have made those workers safer and would have improved their terms and conditions?

    Findlay - Neil+Findlay+CJjkOng3r8Em

    Labour MSP Neil Findlay – give care workers safer workplaces.

  • Jeane Freeman: 

    I disagree with those amendments and do not believe that that is what they would do. There are other approaches. I will not get into a debate about that emergency legislation, as that would not be appropriate at this point, but the amendments that we have lodged are the correct ones and I hope that members will support them.

    I am sure that my colleague Mike Russell is more than capable of setting out our clear reasons for opposing certain amendments. I do not think, as the member appears to be implying, that there is any contradiction between my long-standing support—from before I was health secretary—for care home workers and NHS workers, having been one myself many years ago, and the occasions when I may disagree with Mr Findlay.

  • Maureen Watt (Aberdeen South and North Kincardine) (SNP): 

    I, too, welcome the changes to the testing criteria in care homes. How will that work in practice? Will test kits be sent out to care homes, particularly those in rural areas, so that a nurse in the home can carry out the testing or will someone from the health board or social care partnership still be required to visit the home to carry out the tests on staff and residents, thereby causing a delay in the process?

  • Jeane Freeman: 

    That is an important point. Much of our country is remote and rural and requires travel over considerable distances in order to reach places. Depending on what will give us the quickest answer, which will vary, there will be a mix of both approaches. On occasion, if the clinical staff in a care home have been trained to undertake the sampling, they will be able to do that, whereas in other circumstances, testing will be carried out through the deployment of the mobile testing units, of which we have 12 in Scotland. In other circumstances, local NHS staff, such as district nurses or local staff from a nearby acute or primary care setting, will be used.

  • Jamie Halcro Johnston (Highlands and Islands) (Con): 

    It has taken nearly three weeks from when a resident of the Glenisla care home in Moray was confirmed as a Covid-19 case for full testing of residents and staff to be undertaken and the results to be processed. Some of the test results took five days to process. So far, that full testing has identified a further three cases, but the management have told me that they will not be offered secondary testing because it is being focused on priority cases. Will the health secretary confirm that the delay of nearly three weeks is unacceptable and that it will have put the safety of residents and staff at further risk? Will she confirm that Scottish Government guidance is clear that secondary testing should happen when there are confirmed cases and that, if NHS Grampian is not offering that testing, it is in breach of that guidance?

  • Jeane Freeman: 

    If the member cares to give me the details of that particular instance, I will investigate it directly this afternoon and tomorrow and get back to him. It is not acceptable for that to take three weeks and it is certainly not acceptable for tests to take five days to process. I need to know which lab was processing those. Our NHS labs are working to a maximum of 24 hours. They do not always meet that at the moment, but they need to get there by the end of this month and they are actively engaged in doing that.

    Twenty-four hours is the right time period for us to move into test, trace, isolate and support. In some instances, it takes longer than that, but five days is completely unacceptable, as is the situation that the member described with secondary testing. I do not understand why that view was given by NHS Grampian or reported by the manager. I will want to look in great detail at what that was and why anybody thought that it was the right thing to do, because it is not.

  • Ruth Maguire (Cunninghame South) (SNP): 

    Residents and families must be assured that they will receive the highest quality of care and that robust action will be taken when that does not happen. How will new powers that are proposed in the Coronavirus (Scotland) (No 2) Bill help to bolster the work of the Care Inspectorate to ensure that that happens in practice?

  • Jeane Freeman: 

    I will focus on one of the amendments that we have lodged, as a way of—I hope—explaining why we believe that the powers are necessary.

    I preface my comments by saying that we would use these powers as a last resort, but if the Care Inspectorate’s view is that a care home that it has inspected is of such poor quality that it intends to apply to the court to deregister the provider, I do not believe that we can wait for the court to go through its due process—although I am not criticising how long the court may take—before we can step in to ensure that the residents are safe and that infection prevention, cleanliness and the ratio of staff to residents are of the standards that we need.

    In those extreme circumstances, it is important that we can provide that additional safety net and, regardless of the provider’s view or the fact that the court decision is still to be made, move in straight away to protect the residents in the care home. As the member knows, the amendment will then require us to apply retrospectively to the court for its permission to do what we have done.

  • Alexander Burnett (Aberdeenshire West) (Con): 

    Given the tragedies that are occurring in care homes across the north-east of Scotland, what amount of the £58 million that was pledged last week from the United Kingdom Government will go to the north-east, and how will it be distributed?

  • Jeane Freeman: 

    I am not entirely sure what additional funding the member is talking about. I apologise to him—I did not hear clearly what he said. If he is referring to the additional resource that the UK Government has committed to care home work, the consequentials for that will go to care home work in Scotland.

  • Kenneth Gibson (Cunninghame North) (SNP): 

    I declare that my mother lives in a care home.

    Even before the pandemic, many care homes were struggling to survive. In my constituency, care homes have closed in Arran, Largs and Saltcoats in recent years. Financial support from local authorities for those whom they place has struggled to keep up with the rising costs. Now that the additional costs of personal protective equipment, higher wages and a higher staff-to-resident ratio have arisen, what steps will the Scottish Government take to ensure the continued viability of our care homes as the pandemic recedes?

  • Jeane Freeman: 

    As I am sure that the member knows, many of our care homes survive financially on the same basis as some of those that do not. The standards that are required are the standards that are required, and we have already discussed what needs to be done in circumstances in which care homes fail to meet those standards.

    Care homes are subject to a national contract that they negotiate with COSLA through Scottish Care, which sets out the amount that will be paid for each resident whom the local authority asks to be placed in a care home, which is currently done through the health and social care partnerships.

    I am sure that, in addition to the continuing discussions between COSLA and Scottish Care on statutory sick pay and ensuring that care home workers are not put in an invidious position as a result of their employer’s contract of employment, further discussions will take place between those two parties on the national contract, and that not only will I be advised of what those are, but I will hear from both parties what more they think needs to be done.

     

    As we go through this pandemic, we will be actively engaged, not only on the additional resources that are required to get through the pandemic, which I have touched on and which the Scottish Government has made available, but on the continuing sustainability of the care home sector. Some of that engagement will pick up on questions that Ms Baillie and others have raised.

  • Colin Smyth (South Scotland) (Lab): 

    Does the cabinet secretary accept that simply adding new categories to the list of those who can be tested is, in itself, not enough? We know from our communities that many people who are already eligible—such as carers and residents in homes with an outbreak, and carers who are being told to travel miles to access tests—are simply not being tested.

    Will the cabinet secretary consider regularly publishing the numbers of people who are tested by category of eligibility and by health board for each category, so that we can properly scrutinise delivery on the ground? Will she ensure that no one has to travel an excessive distance to access a test?

  • Jeane Freeman: 

    I will commit to publishing what data we have, as best I can. The reason for that caveat is that we do not have all the data on testing that takes place when an individual accesses UK Government mobile or drive-through testing through the employer or employee portal, which is processed at the lighthouse laboratory in Glasgow. If a care home worker, an NHS worker or an oil and gas worker goes through that route, we do not get the absolute data of every category that has been tested. There is a limit to what I can publish, which is the data that comes through our NHS testing.

    We have been consistently clear that NHS and social care workers should be tested by the NHS and their tests processed in NHS labs, which are quicker at turning around test results—notwithstanding the issue that was raised earlier, which I will look at. We have much more direct control over what those labs are doing.

    No one should have to travel miles to access tests through NHS labs. That situation happens when an individual goes through the UK Government employer or employee portal and is directed to one of the drive-through testing centres if a mobile testing unit is not nearby. That is why we want health and social care workers to go through the NHS route.

    I agree with the member that there is no point in adding testing categories or capacity if we do not use that capacity. The capacity that I can control is that of our NHS labs. Work is under way right now to ensure that we can maximise that for all the groups that we have said are priorities for testing, including care home residents, care home workers, NHS staff, over-70s who are admitted to hospital, and others.

  • Sarah Boyack (Lothian) (Lab): 

    I, too, would like to hear the answer to Graham Simpson’s question about test results, as many of us are concerned about that.

     

    Sir Harry Burns and Sarah Boyack talking to Democrat editor Bill Heaney.

    It is welcome that the Government is finally adopting the testing advice of experts such as Sir Harry Burns and Professor Hugh Pennington. The latter also suggested that the R number in care homes was likely to be high. Can the cabinet secretary give us an update on the current estimated R number in care homes?

  • Jeane Freeman: 

    No, I cannot. As I am sure that the member knows, there is a range of experts in this area, in addition to the two that she mentioned. Our advisory group, which is chaired by Professor Andrew Morris, has been asked to look at what the R number might be in certain settings, including care homes. It is working on that.

    The difficulty that the advisory group has is that not every care home has an active case and not every care home has had an active case since the outset of the pandemic. Looking at the sector as a whole is a difficult exercise. Some care homes have significant numbers of cases, some have only one and many have none, so it is difficult for the group to look at the R number with any confidence in its modelling. However, it has given us the assurance that it will continue to work on it and see what it can pull in from experience elsewhere.

    The R number should be a range, and I, too, would find it very useful to know what it is. At the moment, the advisory group’s response is that it is not possible for it to give us an answer with any confidence in its robustness, but we will continue to look at that.

  • Richard Lyle (Uddingston and Bellshill) (SNP): 

    Highgate care home, in my constituency, was one of the first to declare the presence of Covid-19. Many of my constituents want testing to safeguard their loved ones. I have to declare that my brother is a resident of Highgate, and his daughter and grandchild, if they were here today, would surely thank the cabinet secretary for her announcement, as I do.

    How often will staff and patients in care homes where Covid-19 is present be tested? Will it be every week?

  • Jeane Freeman: 

    Where there is an active case of Covid-19, all the staff and residents in the care home should be tested. Staff who test positive should stay at home following the guidance that any of us should follow if we test positive, and residents should receive the clinical care that they need, through their primary care provider, which will be the GP practice. All of that is now overseen by the medical and nurse directors of the health board. Under infection prevention and control measures, care homes are actively scrutinised to ensure that any possibility of transmission from one resident to another is broken, as far as that is possible.

    The member will know that for many residents in our care homes who suffer from dementia, that degree of isolation in their room is particularly distressing. In those circumstances, a degree of clinical guidance is needed that supports care home staff to minimise that distressing situation while other mitigating measures are taken to prevent infection transmission.

    In my statement, I announced that care workers in care homes that do not have an active case will be tested, and that process will repeat every seven days. If, in the first round of testing, any member of staff tests positive, they will be asked to go home and follow the appropriate isolation and clinical guidance that we have spoken about. We would then begin to test the residents in that care home, because we would need to be sure that none of them had contracted the virus.

  • Daniel Johnson (Edinburgh Southern) (Lab): 

    According to the Financial Times, the rate of excess deaths due to Covid-19 stands at 65 per cent in Scotland, which is exactly the same rate as that in Italy and is among the worst in Europe. At the same time, in Scotland, the use of intensive care unit beds peaked at 208 on 12 April, which was just 18 more than the pre-Covid-19 capacity. It is hard to avoid the hypothesis that people have not been admitted to ICU in Scotland who would have been in other countries. The situation in our care homes raises the suspicion that that is even more true for those who are resident in those homes.

    What steps is the cabinet secretary taking to interrogate the data, examine the policy and practice, and ask the question whether people have been refused admission to ICU who should have been, and would have been, admitted elsewhere?

Jeane Freeman: 

As the member said, he is talking about a hypothesis. I would be very careful about suggesting that our clinicians at any level in primary or acute care chose not to provide any patient with the appropriate clinical care for any reason at all. Our chief medical officer has been clear in supporting our GPs and primary care practitioners, as have the BMA GP group and the Royal College of General Practitioners, that individuals should be given the right clinical care for them, regardless of their location. I have no reason and no evidence to suggest that that has not been the case.

That applies, too, in the hospital setting, when an individual is admitted. We have clear guidance from the Royal College of Emergency Medicine about the balance in decision making that is undertaken in any circumstance, and not just in the current pandemic, in considering invasive and intrusive treatment that causes pain and may cause long-lasting harm. We have seen some emerging data about the potential long-lasting harm that is caused to individuals who are admitted to ICU and ventilated for any length of time during the pandemic. Clinicians always have to balance the benefits of the care that could be delivered against the risk of damage and the failure of that care. That is a constant balancing judgment that all clinicians have to make. It is a very difficult place to be, and not one that I would wish to occupy.

Our group that is led by Professor Andrew Morris, along with the National Records of Scotland and our senior statisticians, are looking at the excess death numbers here and in the rest of the UK in order to interrogate those numbers further so that we know as best we can exactly what lies behind them. As they reach conclusions on that, we will of course ensure that members and others are made aware of those conclusions.

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