Written Evidence Submitted by the British Geriatrics Society

(CLL0064)

The British Geriatrics Society (BGS) welcomes the opportunity to contribute to this important inquiry. The BGS is the membership association for professionals specialising in the healthcare of older people across the UK. Founded in 1947, we now have over 4,400 members, and we are the only society in the UK offering specialist expertise in the wide range of healthcare needs of older people. Around half of the diagnoses of COVID-19 have occurred in people aged over 65, and 90% of the deaths from the virus have been in this age group. As such, our members working in primary care, community care and acute hospital settings have been at the forefront of the COVID-19 pandemic and have seen first-hand the impact that this pandemic has had on patients, staff and systems.

Impact of lockdown

For many older people, lockdown poses almost as much threat as contracting COVID-19. Older people have spent months inside, not participating in their normal activities and being far less active than they normally are. At the time of writing, England was in the second period of national restrictions through the autumn. This is particularly challenging for older people who have cognitive impairments and may find it difficult to understand why they are restricted or why they need to take precautions. Many older people are likely to have experienced physical deconditioning as a result, leaving them more susceptible to other illnesses, falls and hospitalisation.

While some sources have suggested that lockdown would have a significant impact on the mental health and wellbeing of older people, some research suggests that this has not necessarily been the case. Brown et al carried out a telephone survey with 142 older people in Bradford to investigate the impact of lockdown on that group. Despite the pandemic, most participants reported low levels of health anxiety, good health, having low levels of depression and anxiety, and good access to services.[1] While the authors acknowledge the limitations of this research (such as excluding those with hearing impairments due to the use of a telephone survey and not being generalisable to older people living with dementia) it does however suggest that the mental health impacts of lockdown on older people may not be as significant as feared.

Despite this, the impact of lockdown will be felt across the NHS and social care long after the worst of the pandemic is over. It seems almost certain at this stage that a vaccine will be made available in the coming months and while experts seem to agree that COVID-19 is something that we will always live with, we will move to a phase where it does not pose the same threat that it currently does. However, many older people will have physically deconditioned during lockdown. Many older people, in particular those advised to ‘shield’ will have developed frailty that they did not have prior to the pandemic. It is vital that the Government invests now in exercise and rehabilitation services to ensure that the long term impact of lockdown on older people is minimised. In addition, it will be important to ensure long term investment in mental health services specifically designed for older people. It is not uncommon for older people to experience loneliness and social isolation and lockdown will have exacerbated this for many. Support to address loneliness as well as specialist psychological therapies (IAPT) services for older people will be essential.

Impact on social care

The impact of the pandemic on the social care sector, and in particular on care homes, has been significant. Care homes were left unprotected, particularly at the beginning of the pandemic, and the consequences have been devastating. Around 40% of the deaths from COVID-19 in the first wave occurred in care home residents. Care homes did not have access to adequate supplies of Personal Protective Equipment (PPE), in the early stages of the pandemic, putting residents and patients at risk. It is essential that this is not repeated during the second wave – care homes must have the same access to PPE as the NHS.

The Government told the public that they had thrown ‘a ring of steel’ around care homes. Unfortunately, very few care homes felt protected with many being asked to accept residents from hospital with no information about their COVID status, thus putting staff and residents at risk. Care homes are not medical environments and many of the demands placed on them by the Government and local health systems were unreasonable.

In addition, guidance for care homes was non-existent at the beginning of the pandemic with initial advice from the Government stating that it was considered ‘very unlikely that anyone receiving care in a care home or the community will become infected.’[2] The British Geriatrics Society published the first guidance on managing COVID-19 in a care home environment in March and we updated this guidance in November. Since first publication in March, the guidance has been viewed 156,000 times, showing the demand for such guidance on managing the virus in a care home environment.[3] At the time of writing, the updated guidance had been online for two days and it had already been accessed 2,000 times, showing that care homes still need support to manage the pandemic among their residents.

Much of the attention during the pandemic has been on older people living in care homes. However, it must be remembered that most older people do not live in care homes, they live in their own homes either with partners or families or on their own. Many of these people will be recipients of home care which will also have been affected by the pandemic. Carers may not have been able to visit as regularly, especially as many care staff have been hit by illness during the pandemic or required to self-isolate. This will have had a significant impact on the health and wellbeing of older people and their unpaid carers who usually rely on this care.

The social care sector has been in crisis for many years and successive governments of both parties have promised yet failed to reform it. The current Government and the current Prime Minister have repeated this promise on several occasions. The pandemic has laid bare the years of failure to fix this issue and it is now more important than ever that this is prioritised. Over the years, there have been various committees and taskforces dedicated to considering the options for a reformed social care system and they have proposed different solutions to this issue. The time for such committees and taskforces has now passed and a decision must be made on how the social care sector will be reformed and what funding will be made available to it. Demand for social care is likely to increase over the coming years with the combination of the ageing population, and the rehabilitation needs of those who have had COVID-19 and those who have deconditioned during the lockdown. While the pandemic will end at some point, the pressure on social care that has been increased during the pandemic is not likely to reduce. Older people who need social care support generally have multiple and often complex health conditions or frailty and require an integrated approach to delivery of their healthcare and social care support to ensure this is coherent and well coordinated.

COVID testing

There was very little access to testing at the beginning of the pandemic and in particular, access to testing for people being discharged from hospitals to care homes was limited. There was no requirement for people being discharged to a care home to have a negative test for COVID-19 and there was no requirement for care home management to be informed of an incoming resident’s COVID status. This denied care homes the opportunity to protect their residents and staff from COVID and to take action to stop the spread of COVID within the care home.

We have heard anecdotally from our members that hospital staff are struggling to access regular testing even now which is particularly concerning as, in many people, COVID-19 is asymptomatic. While we have heard that testing for staff is continuously improving, it is concerning therefore that BGS members who are healthcare professionals working with population groups most at risk of contracting and dying of the virus have not had access to regular testing.

Impact on BAME communities

As the COVID-19 pandemic progressed, it became clear that those from Black, Asian and minority ethnic (BAME) communities were bearing a disproportionate share of deaths from the virus. The diversity of society in the UK is something we should be proud of. Nowhere is this more reflected than in the workforce of the NHS; without the contributions of skilled BAME health professionals at every level, the NHS would collapse. This is also true of those who work in older people’s health and social care, whether in hospitals, care homes or in the community. At the BGS, we are proud to have a diverse and multicultural membership and believe our contribution to improving healthcare of older people is the richer for it.

More than 90% of the doctors who died from COVID-19 have been from BAME backgrounds including, to our great sorrow, three geriatricians – Dr Medhat Atalla, Dr Alfa Sa’adu and Dr Anton Sebastianpillai.

We were pleased to hear a new Race and Health Observatory is being set up by the NHS and we hope this will lead to a more systematic approach to collecting data on race and health, better engagement with BAME healthcare workers, and better understanding of how the academic research can inform the response of the NHS and public health system in dealing with historic and current inequalities.

Existing health inequalities have been magnified by the pandemic among those groups who tend to have worse health outcomes than others. While the pandemic has had a profound impact on those from BAME communities, other inequalities have been magnified as well, including age. The pandemic has exposed an ageism within society, showing attitudes towards older people that would not be accepted for any other population group. 

Government communication and public health messaging

During the first stage of the pandemic and the first lockdown, the Government’s message was ‘Stay home, Protect the NHS, Save lives.’ We have heard anecdotally from our members that many older people took this slogan to heart and did not seek medical attention for non-COVID conditions when they may have needed it. We heard from our members during the first lockdown that they were not seeing as many patients presenting to emergency departments with hearts attacks and strokes as they normally would. In addition, since the end of the first wave of the pandemic, our members have reported that they seem to be seeing more older people with new diagnoses of advanced cancer, suggesting that people experiencing symptoms of early cancer delayed seeking help until they considered it to be safer. Although this is anecdotal evidence, we have heard similar stories from members across the country, suggesting that these experiences are not isolated. It appears that the Government messaging to ‘Protect the NHS’ may have worked a little too well in the older population and the NHS will now need to work hard to ensure that those people who did not seek medical treatment during the worst of the pandemic are prioritised as services get back to normal.

During the first wave of the pandemic decisions were made regarding the rationing of hospital treatment and intensive care which negatively affected older people. While it is important to remember that some older people who are living with severe frailty and multiple chronic conditions would not have benefitted from invasive and potentially futile critical care, serious concerns about equitable access to treatment have been raised. These decisions were not being made on the basis of clinical need but rather on the basis of age. Older people are as entitled as other age groups to care based on an individualised assessment weighing the potential risks and benefits of any treatment. As we move through the second wave of COVID, it is essential that experts in the care of older people are involved in these decisions to ensure that older people have access to the care that they need.

In addition, many non-COVID services were cancelled during the pandemic as resources within the NHS were focused on treating those with COVID and protecting those without. This included outpatient clinics such as falls prevention clinics and community rehabilitation and support services. These services are essential as they help older people and their carers to stay healthy at home, reducing demand on emergency services and releasing hospital and care home capacity. As non-COVID services are restarted, it is essential that these services are given the same level of priority as more high-profile services such as cancer diagnosis and treatment.

Despite the knowledge at a reasonably early stage that this virus was more likely to severely affect older people, it was unclear at the beginning from where, if anywhere, the Government was getting advice on how the pandemic would affect older people. Our members suggested at a very early stage that the virus may present differently in older people and that the usual symptoms of a cough, fever or breathlessness might not be as applicable to the older population.[4] Despite this, it was many months before other symptoms such as delirium were added to the official list and many of the symptoms reported by our members would still not qualify someone to access a COVID test. Some of our members working in hospitals report diagnosing COVID as the result of a test given when a patient comes into hospital following a classic geriatric presentation such as a fall or delirium rather than patients presenting with the respiratory symptoms that have been well promoted. It is disappointing that the Government has not taken steps to promote the ‘atypical’ symptoms of COVID-19 that occur in older people, especially to care homes. If care homes had been given more information about how COVID presented among older people, they may have been able to identify COVID earlier and take steps to stop the virus spreading throughout the home.

Development of treatments and vaccines

We have been heartened by news that the vaccines that have thus far been developed for COVID-19 appear to be effective in older population groups. The Government’s draft guidance on which population groups will be prioritised to receive the vaccine suggests that older age groups and those in care homes will be among the first to receive the vaccine. We are hopeful that this remains the case when final guidance is issued. The public discourse regarding the pandemic has focused on getting back to normal and protecting the economy. When the vaccine becomes available the Government may find themselves under pressure to first make the vaccine available to younger people in order to allow everyday life to return to normal and to help protect the economy. It will be important to ensure that those most at risk of contracting the virus, and dying of it, are prioritised when it comes to vaccinations.

While most deaths from COVID-19 have been among older people, it is important to remember that the vast majority of older people who are diagnosed with COVID-19 are treated and recover from it. As such, it will be important to consider the impact that having had COVID-19 will have on people’s lives going forward including Long COVID. While we currently do not know a lot about Long COVID, evidence so far suggests that it is a long running illness for which people are struggling to get the treatment and support that they need. In addition, older people who have had COVID are likely to experience an onset of frailty or, for those who had already developed mild or moderate frailty, an exacerbation of their frailty symptoms. As we move out of the pandemic, it will be important for the NHS and social care services to be prepared to support a considerable number of people who need support that they did not need before.

Dr Jennifer Burns                                  Dr David Attwood
President                                              Honorary Secretary

(November 2020)