PHE warned in February against discharges into care homes where there was risk of coronavirus transmission

Sarah Knapton
Eothen Homes care home in Whitley Bay, Tyneside, where all staff and residents are being tested for coronavirus - PHE warned in February against discharges into care homes where there was risk of coronavirus transmission - PA
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Public Health England (PHE) warned as early as February that elderly people should not be discharged from hospitals into care homes if there was risk of coronavirus transmission, new documents show.

The Government has been heavily criticised for not testing patients before they were transferred, despite repeated warnings from care home managers that it was seeding infections among the most vulnerable.

Now it has emerged that as early as February 24, PHE National Infection Service had issued guidance for coronavirus suggesting it was not safe to discharge untested individuals to care homes from hospitals where there was an outbreak of 5-25 cases.

The report advised there should be "no discharges to care or residential homes", adding: "Patients who are not cases, do not have Covid-19 compatible symptoms and are medically fit for discharge could be discharged to own home with isolation/household quarantine."

The  guidance was changed on March 19th so that hospitals no longer needed to avoid sending patients to care homes, a decision which was heavily criticised and which was reversed by the government later on in the epidemic. 

On March 26, The National Care Forum wrote to Matt Hancock and Boris Johnson warning that care homes were being pressured into taking hospital discharge patients who had not been tested for the virus, even though they were exhibiting symptoms. 

Managers said they were forced to play ‘Russian roulette’ with residents and by April 10 industry bodies were reporting that 1,000 people may have died in care homes, even though official statistics showed just 20. 

Care home Covid-19 outbreaks by local authority

On the same day, the National Care Forum wrote again to the Government, urging once more for discharged patients to be tested or risk litigation over the ‘avoidable deaths’ of residents who subsequently became infected.

It was not until April 15 that the Government published its adult social care action plan which announced that trusts would need to test every single patient prior to discharge back to their care home or new admission to a care home whether they had symptoms or not. 

The NHS says it complied with official guidance throughout. 

An NHS spokesperson said “This story is wrong as it overlooks that the guidance of February 24th was replaced by further advice from government on discharges to care homes published on 19th March, and the NHS has followed all advice from PHE and government, throughout this pandemic.”

 

Here is what the rest of the Sage documents say: 

Contact tracing 

PHE advised that contact tracing would need to be abandoned as early as February 12, new Sage documents show.

Analysis by PHE, Cambridge University and the University of Manchester concluded that once cases reached a certain amount there would be little point in continuing contact tracing.

But they also accepted PHE capacity was insufficient to continue with the strategy and warned even if they increased it 10-fold it would not be enough.

The UK has been much-criticised for abandoning contact tracing on March 13 while other countries, which have achieved a lower death toll, continued to trace contacts and cut off routes of transmission for the virus.

The report said that when cases start to spread to several generations and infection numbers rise, then case and contact isolation (CCI) "is expected to be of limited benefit outside of certain special cases and should be discontinued".

The document said: “The current PHE based capacity to provide CCI can be expected to be not sufficient, or sustainable, at the limits of controlling higher rates of incursions into the UK, and should be enhanced.

“We recommend that a practical and reasonable level of enhancement should be to enable a 10-fold increase in capacity to provide effective CCI controls.”

The report sets out how, faced with continuing "and potentially escalating" cases, PHE's capacity to contact trace would need to be increased.

“Scaling this response up, using for example a call-centre type system to support the local PHE teams, should be possible and feasible,” it said.

However, the report concluded that contact tracing would become potentially unsustainable when the number of infections resulted in more than 8,000 contacts needing to be traced each day.

Face masks 

Government scientists saw evidence that widespread use of face masks could have an 'important' or 'major' impact on the spread of Covid-19, but still decided against recommending the measure.

Newly-released papers from April 13 show that Nervtag (New and Emerging Respiratory Virus Threats Advisory Group), which feeds into Sage, considered modelling which, even on a pessimistic forecast, suggested a benefit to the universal wearing of face masks.

However, because of the dearth of high-quality trials underpinning the models, they concluded there was insufficient evidence to endorse the measure.

The papers were released the day after the Government announced it will become mandatory to wear face coverings on public transport from next Monday.

Is the face masks policy a good idea

The Nervtag briefing document states: “Modelling studies are highly dependent on initial assumptions of mask effectiveness but suggest a potential major benefit of universal face mask wearing, especially if masks are assumed to be highly effective.

“Modelling suggests a much lower, but potentially important benefit if masks are assumed to be less effective. In the context of limited mask supply models suggest that it should be targeted at symptomatic infectious patients and those at high risk of severe disease.”

Scientists believe the main benefit of masks is to reduce the risk of people with Covid-19 infecting others.

Randomised trials - the quality benchmark in scientific research -  have been undertaken which did not show a protective effect, but these are believed to have been undermined by poor adherence by the participants.

The Government has justified its decision to impose face coverings at this stage rather than earlier in the crisis on the basis that more people are using public transport, where keeping two metres apart from other passengers is often impossible.

However, because of the reduced numbers of services, there have been instances of crowding since all the way through the pandemic.

Speaking on Thursday, Grant Shapps, the Transport Secretary, said: “As passenger numbers increase, and we expect this trend to continue, we need to ensure every precaution is taken... the face covering helps protect our fellow passengers. It’s something we can do to help each other.”

Nervtag also considered the impact that universal mask-wearing might have on behaviour.

“In the Covid-19 pandemic, symptomatic individuals should be self-isolating rather than wearing masks in public,” the document states.

The Government has asked people to make their own masks, such as out of T-shirts, rather than using clinical masks so as not to deprive NHS staff who have suffered from shortages of Personal Protective Equipment.

Flights

More than 42,000 air passengers arrived in the UK from Spain in the four days before lockdown, prompting Home Office officials to enquire about flight bans.

A request for guidance, sent to Sage the day before Boris Johnson announced the shutdown, warned that given the size of the outbreak in Spain and the number of flights from there per day, the country posed the highest risk to the UK of any in Europe.

Sage had previously advised that restricting travel to the UK would have little impact on the progress of the epidemic.

But, citing Border Force National Control Centre figures, the Home Office said: “We would appreciate Sage’s advice on whether restrictions either broadly or specifically would now be sensible”.

No such flight restrictions were imposed.

However, The Government has subsequently announced plans for 14 days of quarantine for people arriving to the UK.

Travel restrictions to European destinations

Industry figures and many Conservative backbenchers say the measure is unwarranted and could spell disaster for large portions of the travel sector.

Sent to Sage on March 22, the document states: “For Italy, France, and Germany the numbers of passengers arriving are low and we can have confidence that these countries are at a roughly similar stage of the epidemic to the UK (recognising that Italy, at least, is two to four weeks ahead).

“Thus, for these countries the impact of stopping flights would be very low.

“Spain is also likely to be at a similar stage of the epidemic, but the Annexes show that the number of passengers arriving is far higher than for Italy, France and Germany.

“If passengers continue to arrive from Spain in such high numbers, this makes flights from Spain, relatively speaking, a higher risk.”

Post-coronavirus air travel:

The prevailing view within Sage has always been that only once the epidemic is contained within the UK is it worth making an effort to stop cases coming in from abroad.

The official figures showed that 15,560 passengers arrived from Spain on the Thursday before lockdown, 17,604 on Friday, 7,555 on Saturday and at least 2,000 on Sunday.

The numbers from Spain are considerably higher than those from Italy, Iran, Germany and France - all considered “hotspots” - combined.