Nick Kempe: What’s happening with rehabilitation in care homes in Scotland?

“The health impacts of Covid-19 shouldn’t just be assessed in terms of those who have died, but also by looking at the lives of those who have survived.”

THERE is increasing awareness, backed by research, of the long-term health impacts of Covid-19 on people who have had the illness and new organisations committed to publicising this. Covid-19 does not impact on everyone equally, of course, with some people who have tested positive appearing to suffer few or consequences. But the people affected include far more than those who have been in intensive care.   

A recent small study from Germany for example, reported in the Journal JAMA Cardiology, looked at the impacts on 100 people who had been randomly selected for MRI scans. On average, 71 days after testing positive for Covid-19, a whopping 78 per cent showed abnormal findings independent of pre-existing conditions. This was higher than the c20 per cent who reported chest pains and the 30% who reported shortness of breath. Helped by tools like the Kings College Symptoms Study app, new side-effects are being identified and many studies are now being conducted across a range of medical specialities. The strong message from this research is that the health impacts of Covid-19 shouldn’t just be assessed in terms of those who have died, but also by looking at the lives of those who have survived.

Two weeks ago, there was a very interesting programme on Inside Health about some of the rehabilitation work that is being done to help people recover in England’s hospitals. Rehabilitation in the NHS has been revolutionised in the last 30 years, with the emphasis now on starting rehabilitation as soon as someone has had treatment; or, where the need can be predicted beforehand, “pre-habilitation”, as it is called. For example, if people lie in bed in hospital for even a couple of days, they lose muscle.  After a couple of weeks, anyone would be left struggling physically, however fit beforehand. This is not just bad for people individually, it is bad for the healthcare system, blocking hospital beds and increasing the risk of falls.

The BBC programme revealed how rehabilitation principles are being applied to Covid-19 patients even while people are on ventilators in Intensive Care Units. There is now equipment that can help keep people’s arms and legs moving, even while they are unconscious – amazing stuff. The speed of learning in modern medicine is incredibly fast and the NHS in hospitals is particularly good at incorporating this into practice.

This raises the question what rehabilitation is being offered to the older people who have survived Covid-19 in Scotland’s care homes? Up until 28 July, when the Scottish Government changed how the data was reported, there had been 6,884 cases of suspected COVID-19 in 697 (65 per cent) adult care homes and c.2000 deaths. That means that there were c4,884 people in care homes who survived Covid-19. While there are some very old people who survive Covid-19 without many after-effects, generally all the evidence shows its impacts increase the older you get. Therefore, it is almost certain that there are several thousand older people in care homes who need some form of rehabilitation.

Other factors, specific to the care home sector, are likely to have increased this need for rehabilitation further. The serious staff shortages that reached crisis point as a result of outbreaks of Covid-19, together with the very low levels of training provided to the workforce, suggests that very few older people confined to their beds will have been helped to retain muscle strength while ill. For those able to walk, the impact of being confined to their room is likely to have been significant. The consequences, both for the quality of life of the older people involved and for the staff that care for them, is likely to be serious.  An issue therefore that one would have thought should be of pressing national concern.

That this aspect of the care home scandal has been kept out of the public eye can be explained by a number of factors including: the continued  restrictions on visits into care homes, the constraints on frontline in the social care sector being allowed to speak out, and the narrow focus of the limited inspections of care homes that have taken place (which I touched on in my report published on Commonweal last week.

Last Thursday, two months after the World Health Organisation had updated its clinical guidance to countries to include the need to consider rehabilitation, the Scottish Government announced the creation of a new National Advisory Board for Rehabilitation and issued a framework for people recovering from Covid-19.  The document was produced by a working group of 14 civil servants with one external representative, from the Health and Care Alliance. There were no rehabilitation practitioners on the group, no staff from health and care partnerships and not a single representative from providers, whether private or public, residential or community based. Yet the new framework purports to be based on “a partnership approach to rehabilitation”.

The approach certainly is all-encompassing, including not just those who have been affected directly by Covid-19, but those who have been indirectly affected and the interface with the rehabilitation needs of those suffering from other health conditions. It ticks a lot of policy boxes. The agenda which it sets out, “redefining rehabilitation services fit for the 21st century”, goes far beyond mitigating the impacts of Covid-19 on those who have experienced it.

There is, however, no attempt to quantify the resources necessary to achieve these grand aims. Nor is there any attempt to set out what needs to be done immediately to address the impacts of Covid-19.  These the framework describes as “wide ranging and as yet unquantifiable”. Instead, responsibility is passed on to local health and social care partnerships:

“The Rehabilitation principles and priorities in this framework should be used by those planning services to ensure the rehabilitation needs of their local population are met. This will involve reviewing delivery in the wake of the coronavirus (COVID-19) to assess whether to continue with prior/existing services, or whether to re-design taking into account new approaches implemented during the pandemic and alternative innovative models of delivery”

It is not explained how these local health and care partnerships, which were already seriously under-resourced, are meant to deliver half of what they are now apparently being expected to do:

“Rehabilitation programmes should be orientated around patient needs and goals and may entail exercises; education and advice on self-management strategies (including for cognition, swallow and activities of daily living); respiratory techniques (such as breathing exercises and techniques); provision of assistive products; caregiver support and education; peer-to-peer groups; stress management; and home modification”

Nor how “the individual and their family or carers” will be “put at the centre of the approach and see the right person in the right place at the right time”. 

For any care home resident who, weakened by Covid-19, has fallen and died as a result, it is already too late.  For care homes only further delays are promised: “We will develop principles and guidance to inform rehabilitation support for care home residents”. That is one of just three references to care homes in the framework and is the only practical commitment.

As Ben Wray has also argued on Source, the evidence increasingly suggests that the Scottish Government is trying to absolve itself from the care home disaster by heaping responsibility onto the workforce while failing to provide the resources which would enable effective action. 

What older people in care homes need is not yet more policy – it is largely irrelevant to making what remains of their lives worth living – but action.

Reading between the lines of the new framework, it appears that older people are not the priority.

The pandemic has significantly challenged our fiscal environment so it is essential we recognise the need for occupational health services and vocational rehabilitation to aid socio-economic recovery by enabling people to return to work or educational programmes”

Furthermore, “Rehabilitation approaches add real, proven value in reducing unnecessary expenditure and resource use…”

The message seems to be the needs of the capitalist economy comes first, with the implication being it is cheaper to let older people in care homes die.  Or in their words: “Ensuring that people are appropriately supported during their recovery so that they can regain their health and wellbeing, and reach their potential so that we can flourish as a nation“.

The implication, despite the claim in the report that human rights are at the centre of the framework, is older people don’t matter.  The people who have suffered most, appear the lowest priority for action.

What needs to be done?

Jeane Freeman promises the framework should deliver “a practical, accessible strategy to deliver quality rehabilitation to everyone who needs it” without giving a single indication of what the Scottish Government intends to do to make this happen. 

Any rehabilitation plan for care homes needs to start with the recognition that public sector community health and care services are currently insufficient to provide the type of individual bespoke quality rehabilitation that older people deserve and that care home staff have not had the training that would enable them to assist with this. The position is very different to hospitals which are much better resourced with rehabilitation expertise.

There are, however, sufficient resources in the system to provide some rehabilitation to all who need it, with a little government support.  GPs, who have the skills to identify the main physical and mental health needs that require to be addressed and to prioritise the people who might benefit from specialist rehabilitation, are the obvious starting point. There are people with the skills (including those in the Care Inspectorate leading the Care About Physical Activity programme referred to in the report) who could, if asked, produce very quickly a national rehabilitation programme for use by care home staff. This would be in the interests of both residents and the staff who will be struggling at present with increased dependency levels.

However, for such a programme to be effective, the Scottish Government would need to make the training mandatory, starting with every care home that has experienced Covid-19, introduce arrangements to ensure that staff are paid to attend training and also ensure staffing levels are increased so that staff have the time to do the work. It would require some urgent reform of workforce pay and conditions as advocated, for example, by GMB Scotland in their report “Show you care” issued on Monday.

The other priority should be to remove wherever possible the restrictions that have done so much damage to the mental well-being of residents. Primarily, this should mean enabling care home residents to spend time safely with their families – the best therapy is being loved – and, where this is not possible, to receive more attention from staff and be able to undertaken activities that are meaningful to them. That again requires staff to have the time and requires further investment to prevent Covid-19 entering care homes (testing of residents, staff and visitors, re-design of building to create safe spaces for people to meet etc).

These practical proposals could be quickly developed by the new National Advisory Group on Rehabilitation if it set up a sub-group on care homes. It should then, however, be the responsibility of the Scottish Government to make available the resources that would enable all care home staff to develop the necessary skills and to ensure that providers devote the necessary resources to enable them to do so. The Care Inspectorate could then be given responsibility for reporting to the Scottish Parliament on the effectiveness of the rehabilitation programmes, providing countrywide recommendations for improvements and tasked with taking enforcement action when required.