Last reviewed 13 July 2020

The World Health Organisation announced in March that the rapid spread of Covid-19 around the world could be termed a “pandemic”, therefore creating a crisis for every government’s public health authorities. Governments had to act quickly to impose measures to reduce the imminent spread of this “novel” virus in their country and to provide effective care and treatment for those who contracted it. Care expert Chris Payne looks at where we are now, the opportunity for reflection on its impact and the potential way forward for care services.

It is generally accepted now that the UK Government’s initial policy response underestimated the extent and potential severity of the outbreak on the population at large. The introduction of the Coronavirus Act 2020 on 25 March 2020 and the implementation of the Health Protection (Coronavirus, Restrictions) Regulations 2020 and swathes of government guidance soon following was a recognition that the crisis was much bigger than had been previously thought.

At this point health and care services were already experiencing the crisis head on, with the number of people who died in hospital peaking on 8 April and the number of people who were residents of care homes who died peaking on 17 April. These figures suggest that infection levels were increasing rapidly in the weeks before, which is supported by the fact that the peak number of 1008 reported outbreaks of infectious illnesses in care homes occurred in the week of 6 April. These reports of outbreaks have fortunately steadily declined to 58 at the end of June 2020, with a corresponding decline in the numbers of residents of care homes who have died from or with Covid-19.

Where are we now?

The situation that exists at the beginning of July 2020, three to four months on from the start of the epidemic, suggests the following.

  1. The initial crisis has passed, but there is still no room for complacency and there can be no relaxation of the basic infection control measures that remain in place, eg physical distancing, robust infection control hygiene, suitable wearing of PPE and isolation of anyone with or suspected of having the virus.

  2. There is scope for a gradual relaxation of the more restrictive measures imposed by “lockdown” to allow resumption of visiting in controlled conditions and more social interaction within the homes through the creation of “social bubbles”. There is likely to be further phased relaxation to allow life to return to normal as far as possible while staying alert to the continuing risks from the virus.

  3. There should be some preparation and planning for a possible so-called “second wave” of Covid-19.

  4. There is also an opportunity to take stock and reflect on:

    • what have been the experiences to date

    • what have been the challenges

    • how have they been faced and with what effects

    • how might we look forward into the long term future when all this has passed.

In terms of the practicalities, the first three aspects will be to a large extent externally driven through government guidance and regulations. The last requires introspection on the part of the care provider. Grasping the opportunity for reflection, review and learning should help the care service recover in the longer term from the effects of these experiences, which have been so stressful to all concerned. How might they go about this?

Remember — care services are about people

Many businesses are producing “recovery plans” to show how they will restore their operations. Such plans focus on economic recovery from any downturns from the lockdown situation. Care services, of course, will have been affected economically as any other business, but as people-serving organisations there will be substantial human costs. Unless these are identified and addressed, they will surely impede full recovery in the care service’s ability to achieve its purpose as a caring organisation.

We know that when people as individuals, families or organisations are thrown into a state of crisis, their abilities to cope are often at the expense of their abilities to recover from the crisis. They use up so much of their resources in weathering the storm that they are physically and emotionally exhausted and have nothing left in reserve in the calm that follows.

This weakens their abilities to cope with future storms. In the context of Covid-19, the so-called “second wave” threatens to be more severe than the first because it could well coincide with the onset of other seasonal infectious outbreaks such as influenza and norovirus, and because the human resources to face these new challenges have been depleted by the first wave and have not been restored to full working health. It will be important to use any respite to recharge batteries and to build up resilience to face future threats.

Where does recovery start?

All care services have been destabilised by the Covid-19 situation. Some clearly have been more severely hit than others. There can be no common starting point for services’ recovery plans. Each has to proceed at its own pace.

There are inevitably strong feelings during and after a crisis. The difference is that during the crisis emotional energies are devoted to addressing the challenges that the crisis poses, and which in the case of Covid-19 have been all-absorbing. Respite allows different feelings to come into play and it is important that these are consciously addressed for recovery to take place.

For example, service users, relatives and staff may experience the following.

  • Anger — for any felt shortcomings in the service’s responses to the crisis such as from lack of appropriate care, shortage of PPE and general failure to implement the required infection control measures. People will need opportunities to express their anger to prevent it either intensifying or turning into chronic hostility that will be even more difficult to address.

  • Bereavement and loss — from serious illness or deaths of service users and/or staff, particularly where there has been lack of opportunity for people to say their “goodbyes” and, for example, for a general yearning for things to be as they were. Again people will need opportunities to grieve and express their sense of loss.

  • Stigma — while those who have been working through the thick of the crisis should always be commended and celebrated, there should be no sense of shame felt by those who have made their contributions away from the frontline or who have had to self-isolate because of their own vulnerabilities. Anyone in this position will need to be carefully reintegrated into the service and their working relationships re-established.

  • Guilt and shame — services that have experienced high incidences of severe Covid-19 illnesses and possibly deaths might well feel a strong sense of collective failure and guilt at their perceived shortcomings.

Here it is important to avoid playing any “blame game”. It might be helpful to recognise that chance plays a big part in the spread of any virus, particularly one such as coronavirus that can evidently be passed on by people who have no signs or symptoms. The reasons for some care homes experiencing outbreaks and not others are not known, but they are likely to be complex and are not necessarily due to any failure or success of their respective infection control measures and procedures.

The publicity given to the evident large numbers of care home residents who have died since the beginning of the outbreak will undoubtedly reinforce any sense of failure. What is given less publicity is the fact that since March 2020 the majority of care homes have not had any outbreak.

Recommendations

It is probably better to think of “recovery” as a process rather than as a plan, the different aspects of which will have different starting points and timeframes.

At the appropriate time, assessment will need to made of the full impact of Covid-19 on the following.

  1. The service organisation as a whole, including the effectiveness of its safety measures, working practices and procedures, staffing situation, etc. In reviewing what has happened a service will need to check rigorously and reflectively using the “Strengths, Weaknesses, Opportunities and Strengths” (SWOT) principles.

    Assessment of strengths

    • What have we done to protect service users and staff at different times from the spread of the virus and in compliance with official public health guidance and regulations?

    • What have we done well and can celebrate?

    Assessment of weaknesses

    • What we might not have done which on reflection should have been done?

    • What have we done less well and from which lessons can be learned?

    Opportunities

    • What can we learn from our experiences so far that will help deal with any future outbreak?

    • Did the crisis present any opportunities for development that we should take into the future, such as the “pulling together” and stronger sense of community that has been commonly experienced?

    Assessment of threats or risks

    • What might prevent us from building on our achievements?

    • How might we plan to address these anticipated difficulties?

  2. The service also needs to assess the behavioural and psychological impacts of the measures that have been imposed, such as self-isolation, lack of visiting, physical distancing, the wearing of PPE on the quality of service users’ lives and on staff practices, including communications, working relationships and teamwork. It can assess these aspects against the extent to which they have prevented person-centred care by exploring and examining people’s experiences and accounts.

  3. The physical and emotional impacts will be best explored through the support methods that the service should already be using, including where relevant, back to work discussions, health monitoring, individual and group supervision and an “open door” policy with access to a suitable person for anyone who is overwhelmed by internal stress and distress and who needs immediate relief for their feelings.

  4. Some people might need support to seek professional help through their GP, occupational health, mental health or, where relevant, bereavement counselling services.

The aim should never be to allow a “new normal”, based on the temporary measures to control the Covid-19 outbreak, to become permanent. There might be some features of the experience that have proved useful and might continue to be used, such as new communication tools. It is known that many care services have used the crisis to introduce innovative practices that can be permanently adopted. It will probably never be a case of “moving back to where we were”. But if the service can address the full impacts of Covid-19 on all levels, it should be able to move successfully forward.