Written Evidence Submitted by National Care Forum

(CLL0118)

Re: Concern over PHE Report Published 27 May 2021

Dear Members of the Public Accounts Committee, Members of the Health and Social Care Select Committee and Members of the Science and Technology Committee

We are writing together publicly to express our concern at the way in which the report authored by Public Health England dated April 2021 and only published 27 May 2021 has been represented as providing a definitive response to the question as to whether or not the infection of people within care homes was seeded by those coming into care homes as part of the hospital discharge programme.

The report contains a number of inaccuracies which are unhelpful. For example, on page 4 it states that on the 15 April a policy was introduced where hospitals could only discharge a patient to a care or nursing home once they had received a negative Covid-19 test. This was not the case (as outlined in paragraph 1.30 to 1.33 in the Social Care Action Plan). The policy they are referring to around only discharging those who tested Covid negative was not introduced until the Autumn as part of the winter plan under the introduction of designated settings, a full five months later. The 15 April policy outlined in the Social Care Action Plan did require all those being discharged to be tested, and the status of the test to be relayed but did not stop discharge. It is also unhelpful that that the report does not mention that the ‘Admission and Care of Residents during COVID-19 Incidence in a Care Home’ guidance published on 2 April stated explicitly that residents did not need to be tested at the point of discharge. Without this information it is very easy for the reader to feel that they are looking at information that provides a comprehensive picture, where in reality, testing at the point of discharge from hospital into care homes was not stated policy until 15 April and therefore it was not possible to identify who was or wasn’t Covid positive at the point they entered, or re-entered a care home.

The primary concern in relation to the report is that its main statement, that 1.6% of outbreaks were identified as potentially seeded from hospital, has provided a completely unrecognisable position from that experienced by hundreds, if not thousands, of care providers across the country between March and April. The report provides no meaningful context about how many of the 25,000 people discharged to care homes during this period were in fact tested (see pages 47-48 of NAO report on ‘Readying the NHS and adult social care’).

In reality, the position as a matter of public record, was that during March and up to the 16 April 2020 many people either leaving hospital, or within care homes were not tested because of the national shortfall in the testing capacity. Any tests that were used were reserved for those who demonstrated the government defined symptoms of Covid, which were often not those experienced

by older people (See LESS COVID report for more detail). This is very significant, and it is a shortcoming of the report not to recognise explicitly that this research can therefore draw absolutely no conclusions about the potential for those who may have been asymptomatic and seeded outbreaks that led to deaths. In addition, it does not lay out how outbreak testing happened within a home prior to the introduction of whole home testing in May 2020. Outbreak testing was carried out by local Public Health teams and required only up to 5 symptomatic people to be tested, which did not include staff, and would not necessarily have been directed to include anyone who had left hospital. With this very partial knowledge of the Covid status of the 25,000 people discharged from hospital to care homes, it is not correct to conclude that ‘hospital associated seeding accounted for a small proportion of all care home outbreaks.’

The period that the report covers is extensive, and yet there is no timeline that shows the number of positive results and the comparative time period. From May 2020 onwards there was sporadic whole home testing, which became meaningfully regular by September 2020. It is not clear how many of these positive tests are associated with the period May to October, versus March and April when it is recognised by the report that in fact most of the deaths happened. Without that knowledge explicitly stated, our working assumption based on an understanding of how testing capacity increased, would be that the majority of these positive tests were identified through the whole home testing programme and the hospital testing programme – both of which were enacted well after the peak of the first wave impact in care homes, and after the discharge programme was enacted.

The final point to raise is the dismissive approach within the report to what it refers to as to

‘anecdotal accounts’ from care homes of infections being seeded by discharge. These accounts were based on the real experiences of people, families, care providers and the workforce. These accounts are effectively silenced by the way in which data is utilised within the report. This is an upsetting and seemingly politicised response to support a narrative that implies that hospital discharge was not a primary cause of outbreaks. The complete lack of systematic testing during March and April, and the sole focus on symptomatic testing when it was available, means in reality that it is impossible to determine completely the cause of outbreaks or the proportion of them that were caused by hospital discharge and therefore the very real commentary from homes about their perceived link between discharge and the seeding of infection should be viewed as having at least as much validity as the data presented in the report, if not more.

The report does show definitively that there is data evidencing hospital discharges as a source of outbreak. However, beyond that, the extremely limited picture due to minimal testing should not be extrapolated to suggest that it in any way represents the full picture.

We would recommend that this report is not viewed as evidence in your enquiries, and rather you should call for an independent review which requires the data to be properly contextualised and from which any partial conclusions drawn could be properly grounded. In the absence of that then the only possible conclusion to be drawn from this report is that that during the period between March and April 2020 it is not possible to determine how many outbreaks were seeded from hospital, just that the data makes clear that some definitely were.

Yours sincerely

Vic Rayner, CEO, National Care Forum

David Oliver, Physician specialising in Geriatric Medicine. Previous National Clinical Director for Older People and former President of British Geriatrics Society.

Adelina Comas-Herrera, Care Policy and Evaluation Centre, Department of Health Policy, London School of Economics and Political Science (curator of LTCcovid.org)

Adam Gordon, President Elect British Geriatrics Society, Professor of the Care Older People, Faculty Medicine and Health Sciences, Nottingham University.

(9 June 2021)