By Anna Down, GP at The Argyle Surgery, and clinical lead for The Argyle Care Home Service, Ealing.

As a GP practice with 900 registered patients across 16 nursing or dual registration care homes in the London Borough of Ealing, we have been uniquely placed to observe the consequences of Covid-19 from the earliest stages of the 2020 pandemic.

We have been providing enhanced GP services to this cohort since 2013, 8am to 8pm, all 365 days of the year. Our team includes dedicated administrative support (including telephone and email access), and a full skill-mix pharmacy team, as well as GPs and advanced nurse practitioners. We have seen previous outbreaks of infectious diseases, including multiple concurrent flu outbreaks.

Watching the international Covid-19 epidemics unfold during February and early March, we started to highlight how outbreaks in care homes were inevitable, given the vulnerable patients in close proximity, and the pressures on social care to help free up capacity in the NHS.

Since then, we have diagnosed over 370 suspected cases of Covid-19, resulting in a four-fold increase in average monthly death rates(175 in March-April 2020), a three-fold increase in the prescribing of injectable anticipatory medications, and an estimated 32% mortality rate (up to 43% in over 90’s). Some of our homes lost 50% of patients over a 10 day period.

‘Accessibility of primary care’

Longstanding relationships with management and staff at the care homes we cover enabled us to implement changes to our working patterns very quickly. Each home has a named GP and a routine visit schedule. We switched these to remote visits in mid-March to help reduce footfall through the homes, while keeping our contact and care to a regular schedule.

One of the early challenges was case recognition. In our population, symptoms and clinical presentation of Covid-19 do not fit ‘cough & fever’ pattern. The most frequent symptoms have been sudden loss of appetite (36%) and low oxygen saturations (28%), while 21% of patients were drowsy, lethargic or confused. Sudden reductions in oral intake are thought to be due to loss of smell and/or sore throat. ‘Silent’ hypoxia correlates to delirium, and increased lethargy.

Proactive care and the accessibility of primary care to the care homes allows us to recognise these symptoms and advise isolation early – this was key learning for future outbreaks.

As outbreaks increased, we increased contact with the homes as required, as they needed more frequent and urgent clinical advice. We were able to track outbreaks across the borough and had a clear sense of where to watch. Previous close working with Public Health England, and the local council, clinical commissioning group and others, meant that we were quickly able to escalate suspected outbreaks.

On the ground, knowledge of working patterns, physical layouts and patient characteristics allowed us to inform where PPE or infection control issues were likely to arise.

‘Lessons learned’

Now, care homes are planning to re-open to visitors. There are real risks to not doing so in terms of residents’ wellbeing. But every interaction with the outside world increases the risk of new Covid-19 outbreaks and we must consider how homes can continue to be supported.

We have learned that care homes are not designed for isolation and social distancing. Care homes are designed as institutions to care for people needing additional help and increased social interaction. Even where they are divided into multiple units; laundry, kitchens, maintenance and management will be shared across the home.

Moving residents into cohorts within the same building has not contained infection, and has worsened it in some cases. Bigger homes have more staff and movement between units. Homes with large outbreaks have had up to 65% of residents infected, despite following guidelines and using PPE. Clinical staff also work across units and in several homes.

Patients with dementia who remain mobile walk with purpose freely, interacting with staff and other residents. It is not possible to isolate these patients without considerable distress. Many dementia patients struggle to understand or remember information about social distancing.

‘Advocate appropriately’

Longstanding advance care plans show many patients want to stay at home for end of life care or when unwell, with a significant minority wanting escalation to hospital for potentially reversible causes.

On the ground, it bears consideration what advance care plans look like in a pandemic – a scenario where one is shut in a room with very little interaction, from staff that may well be temporary and who are looking after multiple unwell patients at the same time without support, is probably not what most were envisaging when making advanced decisions.

All decisions around escalation and resuscitation should be individualised and adapted to the current situation too – advocating appropriately for these patients is crucial.

‘Predictable, proactive contact’

Covid-19 has shone a spotlight onto social care and care homes in England, and it has highlighted the inequities to healthcare that exist, both in terms of esteem and access. As the country moves into the next phase of the pandemic, we believe it is both imperative and possible to alter the course and impact of future outbreaks through multi-agency working.

Our experience suggests that for most care homes, proactive contact, including support from a multidisciplinary team, is highly valued. But this needs to be managed according to the needs of each home – many would prefer a less regular, but predictable contact alongside enhanced access for urgent clinical queries, over increased frequency of planned contacts.

We also need to implement clear pathways. A whole system approach, including health and social care, homes and clinicians is required. The continuity offered by primary care is crucial to this, but it cannot be managed by primary care alone.